Healthcare Provider Details

I. General information

NPI: 1437538972
Provider Name (Legal Business Name): PRIME GERIATRIC DENTAL CARE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2015
Last Update Date: 05/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11400 SE 37TH AVE
MILWAUKIE OR
97222-5982
US

IV. Provider business mailing address

11400 SE 37TH AVE
MILWAUKIE OR
97222-5982
US

V. Phone/Fax

Practice location:
  • Phone: 503-774-6355
  • Fax: 503-659-6325
Mailing address:
  • Phone: 503-774-6355
  • Fax: 503-659-6325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD7017
License Number StateOR

VIII. Authorized Official

Name: DR. JOHN T. OKI
Title or Position: SECRETARY
Credential: DMD
Phone: 503-774-6355