Provider Demographics
NPI:1336218403
Name:GROSS, PHILIP JOEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:JOEL
Last Name:GROSS
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 1:101 SW MAIN ST
Mailing Address - Street 2:STE 290
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97204-3228
Mailing Address - Country:US
Mailing Address - Phone:503-223-5125
Mailing Address - Fax:503-221-6915
Practice Address - Street 1:101 SW MAIN ST
Practice Address - Street 2:STE 290
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97204-3228
Practice Address - Country:US
Practice Address - Phone:503-223-5125
Practice Address - Fax:503-221-6915
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD54641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice