Provider Demographics
NPI:1770826224
Name:DENNIS, PETER (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:DENNIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:0720 SW GAINES ST UNIT 213
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4650
Mailing Address - Country:US
Mailing Address - Phone:360-751-2921
Mailing Address - Fax:
Practice Address - Street 1:16455 BOONES FERRY RD STE B
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-4367
Practice Address - Country:US
Practice Address - Phone:503-482-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-03
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD1987301223S0112X
NC2019-006251223S0112X
ORD99161223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery