MEDICARE: KEIZER RAPIDS DENTAL, 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

General Provider Information

NPI Number	:	1720746860
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KEIZER RAPIDS DENTAL, LLC

Provider Business Mailing Address
First Line	:	419 E DREAS WAY
Second Line	:
City	:	NEWBERG
State	:	OR
Zip	:	97132-8800
Country	:	US
Telephone Number	:	503-537-8781
Fax Number	:

Provider Business Practice Location Address
First Line	:	4754 RIVER RD N
Second Line	:
City	:	KEIZER
State	:	OR
Zip	:	97303-4536
Country	:	US
Telephone Number	:	503-393-6286
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. BRIAN ANDREW OGLE
Credential	:	DMD
Telephone Number	:	503-393-6286

Provider Enumeration Date	:	12/06/2021
Last Update Date	:	12/06/2021

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