MEDICARE: SHANNAN R MAHLBERG RDH

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	124Q00000X	Dental Hygienist	H3707	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	H3707	OTHER	OR	ODA

General Provider Information

NPI Number	:	1477707313
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNAN R MAHLBERG RDH

Provider Business Mailing Address
First Line	:	3390 QUAIL RIDGE CT
Second Line	:
City	:	WEST LINN
State	:	OR
Zip	:	97068-3692
Country	:	US
Telephone Number	:	503-505-1335
Fax Number	:	503-723-0621

Provider Business Practice Location Address
First Line	:	3390 QUAIL RIDGE CT
Second Line	:
City	:	WEST LINN
State	:	OR
Zip	:	97068-3692
Country	:	US
Telephone Number	:	503-505-1335
Fax Number	:	503-723-0621

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

Provider Enumeration Date	:	11/05/2008
Last Update Date	:	11/05/2008

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