Provider Demographics
NPI:1609005867
Name:IVERSON, DENNIS (DDS)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:
Last Name:IVERSON
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:PO BOX 490
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756
Mailing Address - Country:US
Mailing Address - Phone:888-468-0022
Mailing Address - Fax:541-504-3907
Practice Address - Street 1:1880 LANCASTER DR NE STE 121
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1069
Practice Address - Country:US
Practice Address - Phone:888-468-0022
Practice Address - Fax:541-504-3907
Is Sole Proprietor?:No
Enumeration Date:2009-07-09
Last Update Date:2011-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9294122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500608150Medicaid