MEDICARE: VISTA ORTHODONTIC GROUP LLC

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry

General Provider Information

NPI Number	:	1366259897
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VISTA ORTHODONTIC GROUP LLC

Provider Business Mailing Address
First Line	:	400 SW BOND ST STE 300
Second Line	:
City	:	BEND
State	:	OR
Zip	:	97702-3798
Country	:	US
Telephone Number	:	541-848-6642
Fax Number	:	541-848-6649

Provider Business Practice Location Address
First Line	:	400 SW BOND ST STE 300
Second Line	:
City	:	BEND
State	:	OR
Zip	:	97702-3798
Country	:	US
Telephone Number	:	541-848-6642
Fax Number	:	541-848-6642

Authorized Official
Title or Position	:	OWNER/ORTHODONTIST
Name	:	BLAIR H STRUBLE
Credential	:	DMD, MSD
Telephone Number	:	541-848-6642

Provider Enumeration Date	:	12/17/2024
Last Update Date	:	12/17/2024

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Directions to “VISTA ORTHODONTIC GROUP LLC ” Practice Location

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