Provider Demographics
NPI:1639176654
Name:RENSCH, JERRY ALLEN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:ALLEN
Last Name:RENSCH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:JERRY
Other - Middle Name:
Other - Last Name:RENSCH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4707 NE TILLAMOOK ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-2057
Mailing Address - Country:US
Mailing Address - Phone:502-287-9710
Mailing Address - Fax:503-281-7098
Practice Address - Street 1:4707 NE TILLAMOOK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2057
Practice Address - Country:US
Practice Address - Phone:502-287-9710
Practice Address - Fax:503-281-7098
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR42661223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics