MEDICARE: BELLA SMILE 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	7195	OR

General Provider Information

NPI Number	:	1881866788
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BELLA SMILE DENTAL LLC

Provider Business Mailing Address
First Line	:	2505 SE HAWTHORNE BLVD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97214-3970
Country	:	US
Telephone Number	:	503-232-3102
Fax Number	:	503-232-4021

Provider Business Practice Location Address
First Line	:	2505 SE HAWTHORNE BLVD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97214-3970
Country	:	US
Telephone Number	:	503-232-3102
Fax Number	:	503-232-4021

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	LYNETTE HALL
Credential	:
Telephone Number	:	503-232-3102

Provider Enumeration Date	:	03/31/2008
Last Update Date	:	03/31/2008

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