Provider Demographics
NPI:1528203601
Name:DIESBURG, ADAM J (DDS)
Entity Type:Individual
Prefix:DR
First Name:ADAM
Middle Name:J
Last Name:DIESBURG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1927 NE BAKER ST
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-2601
Mailing Address - Country:US
Mailing Address - Phone:503-472-2222
Mailing Address - Fax:
Practice Address - Street 1:1927 NE BAKER ST
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-2601
Practice Address - Country:US
Practice Address - Phone:503-472-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-03
Last Update Date:2012-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD91251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice