Provider Demographics
NPI:1437538972
Name:PRIME GERIATRIC DENTAL CARE, PC
Entity Type:Organization
Organization Name:PRIME GERIATRIC DENTAL CARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:T
Authorized Official - Last Name:OKI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-774-6355
Mailing Address - Street 1:11400 SE 37TH AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-5982
Mailing Address - Country:US
Mailing Address - Phone:503-774-6355
Mailing Address - Fax:503-659-6325
Practice Address - Street 1:11400 SE 37TH AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-5982
Practice Address - Country:US
Practice Address - Phone:503-774-6355
Practice Address - Fax:503-659-6325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-28
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD7017122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR071332Medicaid