Provider Demographics
NPI:1760441216
Name:GERIATRIC DENTAL GROUP
Entity Type:Organization
Organization Name:GERIATRIC DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXEC DIR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:A
Authorized Official - Last Name:LINDER
Authorized Official - Suffix:
Authorized Official - Credentials:EXEC DIR
Authorized Official - Phone:503-772-3677
Mailing Address - Street 1:19348 WINDMILL DR
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:92045
Mailing Address - Country:US
Mailing Address - Phone:507-650-5296
Mailing Address - Fax:
Practice Address - Street 1:6319 SE POWELL BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97042
Practice Address - Country:US
Practice Address - Phone:503-772-3677
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD8295122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty