Provider Demographics
NPI:1508839507
Name:ATACK, GREGORY MARK (DMD, FAGD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:MARK
Last Name:ATACK
Suffix:
Gender:M
Credentials:DMD, FAGD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14871 NW DOMINION DR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-2298
Mailing Address - Country:US
Mailing Address - Phone:503-617-4558
Mailing Address - Fax:
Practice Address - Street 1:1585 SW MARLOW AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5176
Practice Address - Country:US
Practice Address - Phone:503-297-1717
Practice Address - Fax:503-292-7711
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD72101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice