MEDICARE: COLUMBIA RIVER DENTAL, P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	1223E0200X	Endodontics
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)
3	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1558549899
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLUMBIA RIVER DENTAL, P.C.

Provider Business Mailing Address
First Line	:	210 INTERSTATE NORTH PKWY SE STE 300
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30339-2233
Country	:	US
Telephone Number	:	770-916-8143
Fax Number	:	770-858-0657

Provider Business Practice Location Address
First Line	:	1531 MARYLAND AVE NE
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20002-7604
Country	:	US
Telephone Number	:	770-916-5028
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF PAYOR RELATIONS
Name	:	GAIL DARDEN
Credential	:
Telephone Number	:	770-916-8143

Provider Enumeration Date	:	02/08/2008
Last Update Date	:	09/02/2025

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