Healthcare Provider Details

I. General information

NPI: 1639117336
Provider Name (Legal Business Name): DENNIS NOWACK DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 07/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4265 SW 109TH AVE
BEAVERTON OR
97005-3028
US

IV. Provider business mailing address

4265 SW 109TH AVE
BEAVERTON OR
97005-3028
US

V. Phone/Fax

Practice location:
  • Phone: 503-754-1875
  • Fax: 503-643-1006
Mailing address:
  • Phone: 503-754-1875
  • Fax: 503-643-1006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3359
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: