MEDICARE: BIOLOGIC DENTAL PC

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	261QD0000X	Dental Clinic/Center	D8706	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	:	1982106407
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BIOLOGIC DENTAL PC

Provider Business Mailing Address
First Line	:	3826 SE LIEBE ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97202-4034
Country	:	US
Telephone Number	:	503-265-9847
Fax Number	:

Provider Business Practice Location Address
First Line	:	973 NW SALTZMAN RD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97229-5647
Country	:	US
Telephone Number	:	503-644-7202
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JEFFREY PETER DEWEY
Credential	:	DDS
Telephone Number	:	503-265-9847

Provider Enumeration Date	:	02/28/2018
Last Update Date	:	06/16/2018

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Directions to “BIOLOGIC DENTAL PC ” Practice Location

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