Healthcare Provider Details

I. General information

NPI: 1912072067
Provider Name (Legal Business Name): JEFFERY EDWIN REDDICKS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 06/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7095 SW GONZAGA ST
TIGARD OR
97223-8309
US

IV. Provider business mailing address

6950 NE CAMPUS WAY
HILLSBORO OR
97124-5611
US

V. Phone/Fax

Practice location:
  • Phone: 503-620-6715
  • Fax: 503-620-8259
Mailing address:
  • Phone: 503-952-2164
  • Fax: 503-526-4418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD6775
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: