MEDICARE: DR. MORRIS N POOLE 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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	92-137596-9921	UT

General Provider Information

NPI Number	:	1578679205
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MORRIS N POOLE DDS

Provider Business Mailing Address
First Line	:	1340 NORTH 600 EAST
Second Line	:	SUITE 2
City	:	LOGAN
State	:	UT
Zip	:	84341
Country	:	US
Telephone Number	:	435-753-0462
Fax Number	:	435-753-7011

Provider Business Practice Location Address
First Line	:	1340 NORTH 600 EAST
Second Line	:	SUITE 2
City	:	LOGAN
State	:	UT
Zip	:	84341
Country	:	US
Telephone Number	:	435-753-0462
Fax Number	:	435-753-7011

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

Provider Enumeration Date	:	08/23/2006
Last Update Date	:	07/08/2007

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