Provider Demographics
NPI:1033259734
Name:GEHRED, CORNELIUS JEROME (DDS)
Entity Type:Individual
Prefix:DR
First Name:CORNELIUS
Middle Name:JEROME
Last Name:GEHRED
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10340 SE DIVISION ST STE 3
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-1269
Mailing Address - Country:US
Mailing Address - Phone:503-256-3199
Mailing Address - Fax:503-256-9383
Practice Address - Street 1:2010 BOTULPH RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505
Practice Address - Country:US
Practice Address - Phone:505-983-1312
Practice Address - Fax:505-983-8170
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD92421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice