MEDICARE: DARREN S HUDDLESTON DMD PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	7749	OR
2	1223G0001X	General Practice Dentistry	7749	OR

General Provider Information

NPI Number	:	1326039025
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DARREN S HUDDLESTON DMD PC

Provider Business Mailing Address
First Line	:	1035 NE 6TH STREET
Second Line	:	SUITE A
City	:	GRANTS PASS
State	:	OR
Zip	:	97526
Country	:	US
Telephone Number	:	541-476-8788
Fax Number	:	541-471-0400

Provider Business Practice Location Address
First Line	:	1035 NE 6TH STREET
Second Line	:	SUITE A
City	:	GRANTS PASS
State	:	OR
Zip	:	97526
Country	:	US
Telephone Number	:	541-476-8788
Fax Number	:	541-471-0400

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DARREN S HUDDLESTON
Credential	:	DMD PC
Telephone Number	:	541-476-8788

Provider Enumeration Date	:	11/02/2005
Last Update Date	:	05/03/2016

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