Healthcare Provider Details

I. General information

NPI: 1639176654
Provider Name (Legal Business Name): JERRY ALLEN RENSCH D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

Provider Other Name: JERRY RENSCH

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4707 NE TILLAMOOK ST
PORTLAND OR
97213-2057
US

IV. Provider business mailing address

4707 NE TILLAMOOK ST
PORTLAND OR
97213-2057
US

V. Phone/Fax

Practice location:
  • Phone: 502-287-9710
  • Fax: 503-281-7098
Mailing address:
  • Phone: 502-287-9710
  • Fax: 503-281-7098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number4266
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: