Provider Demographics
NPI:1730497868
Name:GEHRED FAMILY DENTAL
Entity type:Organization
Organization Name:GEHRED FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CORNELIUS
Authorized Official - Middle Name:
Authorized Official - Last Name:GEHRED
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:503-254-2068
Mailing Address - Street 1:10340 SE DIVISION ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-1269
Mailing Address - Country:US
Mailing Address - Phone:503-254-2068
Mailing Address - Fax:503-252-5820
Practice Address - Street 1:10340 SE DIVISION ST
Practice Address - Street 2:SUITE 1
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-1269
Practice Address - Country:US
Practice Address - Phone:503-254-2068
Practice Address - Fax:503-252-5820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-23
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD8874122300000X
ORD4833122300000X
ORD9242122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty