Provider Demographics
NPI:1548324510
Name:GENZER, GARY LEE (DMD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:LEE
Last Name:GENZER
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 1:5720 SE FOSTER RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-3866
Mailing Address - Country:US
Mailing Address - Phone:503-774-5037
Mailing Address - Fax:503-774-7128
Practice Address - Street 1:5720 SE FOSTER RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-3866
Practice Address - Country:US
Practice Address - Phone:503-774-5037
Practice Address - Fax:503-774-7128
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR45221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR4522OtherOREGON DENTAL SCHOOL