Healthcare Provider Details

I. General information

NPI: 1295846376
Provider Name (Legal Business Name): DEAN B PETTERSON DMD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 NW 1ST ST
GRESHAM OR
97030-7215
US

IV. Provider business mailing address

121 NW 1ST ST
GRESHAM OR
97030-7215
US

V. Phone/Fax

Practice location:
  • Phone: 503-667-1001
  • Fax: 503-663-3500
Mailing address:
  • Phone: 503-667-1001
  • Fax: 503-663-3500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. DEAN PETTERSON
Title or Position: OWNER
Credential: DMD
Phone: 503-667-1001