MEDICARE: DR. PRISCILLA TALL DDS

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	57712	CA

General Provider Information

NPI Number	:	1811133945
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PRISCILLA TALL DDS

Provider Business Mailing Address
First Line	:	38761 CHERRY VALLEY BLVD
Second Line	:
City	:	CHERRY VALLEY
State	:	CA
Zip	:	92223-4233
Country	:	US
Telephone Number	:	951-769-5487
Fax Number	:

Provider Business Practice Location Address
First Line	:	38761 CHERRY VALLEY BLVD
Second Line	:
City	:	CHERRY VALLEY
State	:	CA
Zip	:	92223-4233
Country	:	US
Telephone Number	:	951-769-5487
Fax Number	:

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

Provider Enumeration Date	:	12/18/2008
Last Update Date	:	08/25/2009

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