MEDICARE: FRIENDLY SMILES DENTAL GROUP

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	122300000X	Dentist	8843	OR

General Provider Information

NPI Number	:	1710136221
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FRIENDLY SMILES DENTAL GROUP

Provider Business Mailing Address
First Line	:	2505 SE HAWTHORNE BLVD
Second Line	:	SUITE B
City	:	PORTLAND
State	:	OR
Zip	:	97214-3970
Country	:	US
Telephone Number	:	503-232-3102
Fax Number	:

Provider Business Practice Location Address
First Line	:	2505 SE HAWTHORNE BLVD
Second Line	:	SUITE B
City	:	PORTLAND
State	:	OR
Zip	:	97214-3970
Country	:	US
Telephone Number	:	503-232-3102
Fax Number	:

Authorized Official
Title or Position	:	DENTIST/OWNER
Name	:	DR. BRANDON S LEE
Credential	:	DMD
Telephone Number	:	503-232-3102

Provider Enumeration Date	:	09/09/2008
Last Update Date	:	09/09/2008

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