MEDICARE: PDO 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	:	1750712642
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PDO LLC

Provider Business Mailing Address
First Line	:	2995 W ELLIOT RD
Second Line	:	STE 1
City	:	CHANDLER
State	:	AZ
Zip	:	85224-1670
Country	:	US
Telephone Number	:	480-775-8600
Fax Number	:

Provider Business Practice Location Address
First Line	:	4146 NEUMAN RD
Second Line	:
City	:	SAINT CLAIR
State	:	MI
Zip	:	48079-3234
Country	:	US
Telephone Number	:	480-775-8600
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JARED POPE
Credential	:	DDS
Telephone Number	:	480-332-6111

Provider Enumeration Date	:	12/03/2013
Last Update Date	:	12/03/2013

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