MEDICARE: JONATHAN E BACKER 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	D7805	OR
2	1223G0001X	General Practice Dentistry	D7805	OR

General Provider Information

NPI Number	:	1477629046
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN E BACKER DDS

Provider Business Mailing Address
First Line	:	1551 E MAIN ST
Second Line	:
City	:	COTTAGE GROVE
State	:	OR
Zip	:	97424-2241
Country	:	US
Telephone Number	:	541-942-8437
Fax Number	:	541-942-1350

Provider Business Practice Location Address
First Line	:	1551 E MAIN ST
Second Line	:
City	:	COTTAGE GROVE
State	:	OR
Zip	:	97424-2241
Country	:	US
Telephone Number	:	541-942-8437
Fax Number	:	541-942-1350

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

Provider Enumeration Date	:	11/27/2006
Last Update Date	:	01/09/2019

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