Provider Demographics
NPI:1407153612
Name:TRIPP, JOHN MATTHEW (EPDH, LD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MATTHEW
Last Name:TRIPP
Suffix:
Gender:M
Credentials:EPDH, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4542 AVERILL DR
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-4114
Mailing Address - Country:US
Mailing Address - Phone:541-295-1264
Mailing Address - Fax:
Practice Address - Street 1:212 NE SAVAGE ST STE B
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1361
Practice Address - Country:US
Practice Address - Phone:541-476-8338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-24
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH5633124Q00000X
ORDT-DO-10189132122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122400000XDental ProvidersDenturistGroup - Single Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Single Specialty