MEDICARE: DR. BROCK D HERRIGES DMD

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	1223P0300X	Periodontics	D8371	OR

General Provider Information

NPI Number	:	1942427216
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BROCK D HERRIGES DMD

Provider Business Mailing Address
First Line	:	1130 SE 122ND AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97233-1112
Country	:	US
Telephone Number	:	503-252-5515
Fax Number	:	503-255-1625

Provider Business Practice Location Address
First Line	:	1130 SE 122ND AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97233-1112
Country	:	US
Telephone Number	:	503-252-5515
Fax Number	:	503-255-1625

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

Provider Enumeration Date	:	04/19/2007
Last Update Date	:	07/08/2007

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