Provider Demographics
NPI:1235332834
Name:PETRISOR, DANIEL (DMD, MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:PETRISOR
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-494-8914
Mailing Address - Fax:503-494-0294
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-8914
Practice Address - Fax:503-494-0294
Is Sole Proprietor?:No
Enumeration Date:2007-06-09
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME16886204E00000X
TX21547390200000X
ORMD154906204E00000X
ORD9059204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL148H9OtherBCBS FL
BP1-0026540OtherINSTITUTIONAL PERMIT
FL0022923-00Medicaid
OR500654224Medicaid
OR500651136Medicaid
ORR168529Medicare PIN
OR500651136Medicaid