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General NPI Number Information
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NPI Number | 1760441216
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Entity Type | Organization
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Legal Business Name | GERIATRIC DENTAL GROUP
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Dates
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Enumeration Date | 03/22/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 6319 SE POWELL BLVD
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City | PORTLAND
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State | OR
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Zip | 97042
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Country | US
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Telephone | 503-772-3677
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Fax |
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Provider Business Mailing Address
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Address Line | 19348 WINDMILL DR
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City | OREGON CITY
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State | OR
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Zip | 92045
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Country | US
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Telephone | 507-650-5296
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Fax |
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Authorized Official
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Title or Position | EXEC DIR
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Name | MRS. PAMELA A LINDER
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Credential | EXEC DIR
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Telephone | 503-772-3677
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D8295
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License Number State | OR
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