MEDICARE: DIANNE D APPLEGATE DDS 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	D8502	OR

General Provider Information

NPI Number	:	1598149791
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIANNE D APPLEGATE DDS LLC

Provider Business Mailing Address
First Line	:	4840 SE CESAR E CHAVEZ BLVD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97202-4017
Country	:	US
Telephone Number	:	503-775-9500
Fax Number	:	503-775-4026

Provider Business Practice Location Address
First Line	:	4840 SE CESAR E CHAVEZ BLVD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97202-4017
Country	:	US
Telephone Number	:	503-775-9500
Fax Number	:	503-775-4026

Authorized Official
Title or Position	:	OWNER
Name	:	DIANNE D APPLEGATE
Credential	:	DDS
Telephone Number	:	503-775-9500

Provider Enumeration Date	:	07/17/2015
Last Update Date	:	07/17/2015

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