Provider Demographics
NPI:1003200122
Name:DIENBERG, MICHAEL J (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:DIENBERG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-494-8916
Mailing Address - Fax:503-494-0294
Practice Address - Street 1:1029 MAY ST
Practice Address - Street 2:
Practice Address - City:HOOD RIVER
Practice Address - State:OR
Practice Address - Zip Code:97031-1514
Practice Address - Country:US
Practice Address - Phone:509-593-0109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-26
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD108611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice