MEDICARE: DR. TERRY L ISOM DMD

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	1223E0200X	Endodontics	D6688	OR

General Provider Information

NPI Number	:	1619973070
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TERRY L ISOM DMD

Provider Business Mailing Address
First Line	:	6400 SE LAKE RD
Second Line	:	SUITE 140
City	:	PORTLAND
State	:	OR
Zip	:	97222-2129
Country	:	US
Telephone Number	:	503-496-4766
Fax Number	:	503-496-4700

Provider Business Practice Location Address
First Line	:	6400 SE LAKE RD
Second Line	:	SUITE 140
City	:	PORTLAND
State	:	OR
Zip	:	97222-2129
Country	:	US
Telephone Number	:	503-496-4766
Fax Number	:	503-496-4700

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

Provider Enumeration Date	:	06/21/2005
Last Update Date	:	03/01/2009

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