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General NPI Number Information
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NPI Number | 1568850279
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Entity Type | Organization
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Legal Business Name | BROCK D. HERRIGES, DMD, LLC
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Dates
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Enumeration Date | 01/05/2015
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Last Update Date | 01/05/2015
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Provider Practice Location Address
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Address Line | 1130 SE 122ND AVE
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City | PORTLAND
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State | OR
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Zip | 97233-1112
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Country | US
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Telephone | 971-221-6744
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Fax | 503-255-1625
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Provider Business Mailing Address
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Address Line | 1130 SE 122ND AVE
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City | PORTLAND
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State | OR
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Zip | 97233-1112
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Country | US
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Telephone | 503-252-5515
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Fax | 503-255-1625
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Authorized Official
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Title or Position | PERIODONTIST
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Name | DR. BROCK D HERRIGES
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Credential | DMD
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Telephone | 503-252-5515
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | D8371
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License Number State | OR
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