Healthcare Provider Details

I. General information

NPI: 1174715197
Provider Name (Legal Business Name): JEAN M PACEWIC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2007
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1554 GARDEN ST STE 104
WEST LINN OR
97068-3278
US

IV. Provider business mailing address

1554 GARDEN ST STE 104
WEST LINN OR
97068-3278
US

V. Phone/Fax

Practice location:
  • Phone: 503-655-9300
  • Fax: 503-212-0122
Mailing address:
  • Phone: 503-655-9300
  • Fax: 503-212-0122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number9278
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: