Provider Demographics
NPI:1164265633
Name:THREE RIVERS ORAL AND FACIAL SURGERY LLC
Entity type:Organization
Organization Name:THREE RIVERS ORAL AND FACIAL SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PETRISOR
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MD, FACS
Authorized Official - Phone:503-692-5654
Mailing Address - Street 1:6464 SW BORLAND RD STE D3
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-8861
Mailing Address - Country:US
Mailing Address - Phone:503-692-5654
Mailing Address - Fax:
Practice Address - Street 1:6464 SW BORLAND RD STE D3
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-8861
Practice Address - Country:US
Practice Address - Phone:503-692-5654
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-13
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty