MEDICARE: DR. PATRICK HOWARD ODONNELL 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	122300000X	Dentist	3980	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	OD0018	OTHER	WA	REGENCE BLUE SHIELD

General Provider Information

NPI Number	:	1477524296
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PATRICK HOWARD ODONNELL DDS

Provider Business Mailing Address
First Line	:	PO BOX 499
Second Line	:
City	:	NORTH BEND
State	:	WA
Zip	:	98045-0499
Country	:	US
Telephone Number	:	425-888-2106
Fax Number	:

Provider Business Practice Location Address
First Line	:	133 E PARK ST
Second Line	:
City	:	NORTH BEND
State	:	WA
Zip	:	98045
Country	:	US
Telephone Number	:	425-888-2106
Fax Number	:

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

Provider Enumeration Date	:	01/30/2006
Last Update Date	:	07/08/2007

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