Healthcare Provider Details

I. General information

NPI: 1518927979
Provider Name (Legal Business Name): GORDON ROY HOVERSLAND DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4350 SW CEDAR HILLS BLVD
BEAVERTON OR
97005-2013
US

IV. Provider business mailing address

255 SW 173RD AVE
BEAVERTON OR
97006-4112
US

V. Phone/Fax

Practice location:
  • Phone: 503-644-8666
  • Fax:
Mailing address:
  • Phone: 503-645-1002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5961
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: