MEDICARE: DONALD EDWARD NIEMANN DDS

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	1223P0300X	Periodontics	4384	WA

General Provider Information

NPI Number	:	1417063280
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONALD EDWARD NIEMANN DDS

Provider Business Mailing Address
First Line	:	408 LILLY RD NE STE B
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98506-6954
Country	:	US
Telephone Number	:	360-459-5900
Fax Number	:	360-459-8720

Provider Business Practice Location Address
First Line	:	408 LILLY RD NE STE B
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98506-6954
Country	:	US
Telephone Number	:	360-459-5900
Fax Number	:	360-459-8720

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

Provider Enumeration Date	:	08/22/2006
Last Update Date	:	07/08/2007

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