Healthcare Provider Details

I. General information

NPI: 1053408005
Provider Name (Legal Business Name): PETER JOHN LAX DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2006
Last Update Date: 11/02/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 NE 47TH AVE
PORTLAND OR
97213-2212
US

IV. Provider business mailing address

720 NE LAURELHURST PL
PORTLAND OR
97232-2653
US

V. Phone/Fax

Practice location:
  • Phone: 503-215-2400
  • Fax:
Mailing address:
  • Phone: 503-235-3255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberD5068
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: