MEDICARE: ERIC J DIERKS MD, DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)	D6708	OR
2	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)	MD16391	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1265432025
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIC J DIERKS MD, DMD

Provider Business Mailing Address
First Line	:	1849 NW KEARNEY ST
Second Line	:	STE 300
City	:	PORTLAND
State	:	OR
Zip	:	97209-1453
Country	:	US
Telephone Number	:	503-224-1371
Fax Number	:	503-224-0722

Provider Business Practice Location Address
First Line	:	1849 NW KEARNEY ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97209
Country	:	US
Telephone Number	:	503-224-1371
Fax Number	:	503-224-0722

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/22/2005
Last Update Date	:	06/11/2018

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