MEDICARE: ALAMEDA 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	D6582	OR

General Provider Information

NPI Number	:	1972854628
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALAMEDA DENTAL LLC

Provider Business Mailing Address
First Line	:	2422 NE FREMONT ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97212-2509
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2422 NE FREMONT ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97212-2509
Country	:	US
Telephone Number	:	503-287-1554
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. RONALD C SELIS
Credential	:	D.M.D.
Telephone Number	:	503-287-1554

Provider Enumeration Date	:	09/20/2012
Last Update Date	:	09/20/2012

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