Healthcare Provider Details

I. General information

NPI: 1770826224
Provider Name (Legal Business Name): PETER DENNIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2013
Last Update Date: 06/15/2020
Certification Date: 06/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16455 BOONES FERRY RD STE B
LAKE OSWEGO OR
97035-4367
US

IV. Provider business mailing address

0720 SW GAINES ST UNIT 213
PORTLAND OR
97239-4650
US

V. Phone/Fax

Practice location:
  • Phone: 503-482-7200
  • Fax:
Mailing address:
  • Phone: 360-751-2921
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberMD198730
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2019-00625
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD9916
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: