MEDICARE: DR. DOUGLAS GEORGE MADDESS DMD

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	1223G0001X	General Practice Dentistry	D6737	OR

General Provider Information

NPI Number	:	1326140377
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DOUGLAS GEORGE MADDESS DMD

Provider Business Mailing Address
First Line	:	914 S 4TH ST
Second Line	:
City	:	COTTAGE GROVE
State	:	OR
Zip	:	97424-2702
Country	:	US
Telephone Number	:	541-942-1559
Fax Number	:	541-942-0827

Provider Business Practice Location Address
First Line	:	914 S 4TH ST
Second Line	:
City	:	COTTAGE GROVE
State	:	OR
Zip	:	97424-2702
Country	:	US
Telephone Number	:	541-942-1559
Fax Number	:	541-942-0827

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/01/2006
Last Update Date	:	07/08/2007

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