Healthcare Provider Details

I. General information

NPI: 1538281068
Provider Name (Legal Business Name): GREGORY P DELGADO D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 08/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10115 SW NIMBUS AVE SUITE 350
TIGARD OR
97223-4349
US

IV. Provider business mailing address

1101 SE TECH CENTER DR SUITE 195
VANCOUVER WA
98683-5504
US

V. Phone/Fax

Practice location:
  • Phone: 503-684-7868
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD8390
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberGA10000414
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDE 00010267
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: