Provider Demographics
NPI:1609993104
Name:REID, DWIGHT EDWARD (DC)
Entity Type:Individual
Prefix:DR
First Name:DWIGHT
Middle Name:EDWARD
Last Name:REID
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3644 SE STARK ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-3156
Mailing Address - Country:US
Mailing Address - Phone:503-255-4817
Mailing Address - Fax:503-786-7050
Practice Address - Street 1:13568 SE 97TH AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-6670
Practice Address - Country:US
Practice Address - Phone:503-490-5647
Practice Address - Fax:503-786-7050
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR273541111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician