Provider Demographics
NPI:1649275223
Name:HONGO, GARY S (DMD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:S
Last Name:HONGO
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 1:9732 SE WASHINGTON ST
Mailing Address - Street 2:STE H
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-8405
Mailing Address - Country:US
Mailing Address - Phone:503-255-8996
Mailing Address - Fax:503-255-0778
Practice Address - Street 1:9732 SE WASHINGTON ST
Practice Address - Street 2:STE H
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-8405
Practice Address - Country:US
Practice Address - Phone:503-255-8996
Practice Address - Fax:503-255-0778
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-20
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR59591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice