Provider Demographics
NPI:1720146152
Name:BLEY, DENNIS EARL (DO)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:EARL
Last Name:BLEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4212 NE BROADWAY
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213
Mailing Address - Country:US
Mailing Address - Phone:503-249-8787
Mailing Address - Fax:503-284-5168
Practice Address - Street 1:4212 NE BROADWAY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213
Practice Address - Country:US
Practice Address - Phone:503-249-8787
Practice Address - Fax:503-284-5168
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO25322207R00000X
OR25322207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR22705Medicaid
I14089Medicare UPIN