Provider Demographics
NPI:1649381328
Name:REID, GORDON DOUGLAS (DMD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:DOUGLAS
Last Name:REID
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 1:200 W 9TH ST
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-1913
Mailing Address - Country:US
Mailing Address - Phone:541-296-9535
Mailing Address - Fax:
Practice Address - Street 1:611 SW CAMPUS DR
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3001
Practice Address - Country:US
Practice Address - Phone:503-494-8791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD48641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice