Provider Demographics
NPI:1912072067
Name:REDDICKS, JEFFERY EDWIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:EDWIN
Last Name:REDDICKS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:6950 NE CAMPUS WAY
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-5611
Mailing Address - Country:US
Mailing Address - Phone:503-952-2164
Mailing Address - Fax:503-526-4418
Practice Address - Street 1:7095 SW GONZAGA ST
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-8309
Practice Address - Country:US
Practice Address - Phone:503-620-6715
Practice Address - Fax:503-620-8259
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORD67751223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery