Healthcare Provider Details

I. General information

NPI: 1205101490
Provider Name (Legal Business Name): MELISSA J. WAGES, DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2012
Last Update Date: 12/28/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7471 SW BARBUR BLVD
PORTLAND OR
97219
US

IV. Provider business mailing address

7471 SW BARBUR BLVD
PORTLAND OR
97219
US

V. Phone/Fax

Practice location:
  • Phone: 503-244-9073
  • Fax: 503-244-4086
Mailing address:
  • Phone: 503-244-9073
  • Fax: 503-244-4086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number10347
License Number StateOR

VIII. Authorized Official

Name: DR. MELISSA J WAGES
Title or Position: OWNER
Credential: DDS
Phone: 503-244-9073