Provider Demographics
NPI:1043422942
Name:PAGE, MICHAEL GREGORY
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GREGORY
Last Name:PAGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:GREGORY
Other - Last Name:PAGE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:2824 NE WASCO
Mailing Address - Street 2:SUITE 230
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232
Mailing Address - Country:US
Mailing Address - Phone:503-284-5678
Mailing Address - Fax:503-284-5556
Practice Address - Street 1:2824 NE WASCO ST
Practice Address - Street 2:SUITE 230
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1772
Practice Address - Country:US
Practice Address - Phone:503-284-5678
Practice Address - Fax:503-284-5556
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD69141223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR072459OtherOMAP PROVIDER ID#
OR072459OtherOMAP PROVIDER ID#