Provider Demographics
NPI:1639368582
Name:VISTICA, JEREMY RYAN (DMD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:RYAN
Last Name:VISTICA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12100 MONITOR MCKEE RD NE
Mailing Address - Street 2:
Mailing Address - City:WOODBURN
Mailing Address - State:OR
Mailing Address - Zip Code:97071-9089
Mailing Address - Country:US
Mailing Address - Phone:503-706-5944
Mailing Address - Fax:
Practice Address - Street 1:12100 MONITOR MCKEE RD NE
Practice Address - Street 2:
Practice Address - City:WOODBURN
Practice Address - State:OR
Practice Address - Zip Code:97071-9089
Practice Address - Country:US
Practice Address - Phone:503-706-5944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-16
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD8993122300000X
VA0401417561122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500637605Medicaid