Healthcare Provider Details

I. General information

NPI: 1447258223
Provider Name (Legal Business Name): GARY THEODORE PEDERSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 07/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1565 LIBERTY ST SE
SALEM OR
97302-4345
US

IV. Provider business mailing address

1565 LIBERTY ST SE
SALEM OR
97302-4345
US

V. Phone/Fax

Practice location:
  • Phone: 503-581-0223
  • Fax: 503-581-6794
Mailing address:
  • Phone: 503-581-0223
  • Fax: 503-581-6794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD4658
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: