MEDICARE: WAVERLY DENTAL 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	122300000X	Dentist		OR

General Provider Information

NPI Number	:	1477979516
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAVERLY DENTAL LLC

Provider Business Mailing Address
First Line	:	721 WAVERLY DR SE
Second Line	:
City	:	ALBANY
State	:	OR
Zip	:	97322-5080
Country	:	US
Telephone Number	:	541-928-8434
Fax Number	:	541-928-2756

Provider Business Practice Location Address
First Line	:	721 WAVERLY DR SE
Second Line	:
City	:	ALBANY
State	:	OR
Zip	:	97322-5080
Country	:	US
Telephone Number	:	541-928-8434
Fax Number	:	541-928-2756

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	SHAWN R GRIFFIN
Credential	:
Telephone Number	:	541-929-5227

Provider Enumeration Date	:	03/13/2014
Last Update Date	:	03/13/2014

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Directions to “WAVERLY DENTAL LLC ” Practice Location

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