MEDICARE: TABLE ROCK FAMILY DENTISTRY, 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	1223G0001X	General Practice Dentistry		OR

General Provider Information

NPI Number	:	1497297923
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TABLE ROCK FAMILY DENTISTRY, LLC

Provider Business Mailing Address
First Line	:	21 S FRONT ST
Second Line	:
City	:	CENTRAL POINT
State	:	OR
Zip	:	97502-2242
Country	:	US
Telephone Number	:	541-664-3335
Fax Number	:

Provider Business Practice Location Address
First Line	:	21 S FRONT ST
Second Line	:
City	:	CENTRAL POINT
State	:	OR
Zip	:	97502-2242
Country	:	US
Telephone Number	:	541-664-3335
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	LUKE B. MURPHY
Credential	:	DMD
Telephone Number	:	541-878-2115

Provider Enumeration Date	:	11/15/2016
Last Update Date	:	11/15/2016

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