Provider Demographics
NPI:1043528169
Name:GEHRED FAMILY DENTAL
Entity Type:Organization
Organization Name:GEHRED FAMILY DENTAL
Other - Org Name:WILSHIRE FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CORNELIUS
Authorized Official - Middle Name:
Authorized Official - Last Name:GEHRED
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:503-284-6469
Mailing Address - Street 1:4839 NE 42ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97218-1609
Mailing Address - Country:US
Mailing Address - Phone:503-284-6469
Mailing Address - Fax:503-288-0490
Practice Address - Street 1:4839 NE 42ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97218-1609
Practice Address - Country:US
Practice Address - Phone:503-284-6469
Practice Address - Fax:503-288-0490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-23
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD92421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty