Provider Demographics
NPI:1568850279
Name:BROCK D. HERRIGES, DMD, LLC
Entity Type:Organization
Organization Name:BROCK D. HERRIGES, DMD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PERIODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BROCK
Authorized Official - Middle Name:D
Authorized Official - Last Name:HERRIGES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-252-5515
Mailing Address - Street 1:1130 SE 122ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-1112
Mailing Address - Country:US
Mailing Address - Phone:503-252-5515
Mailing Address - Fax:503-255-1625
Practice Address - Street 1:1130 SE 122ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1112
Practice Address - Country:US
Practice Address - Phone:971-221-6744
Practice Address - Fax:503-255-1625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-05
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD83711223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty