Provider Demographics
NPI:1861563033
Name:ORTIZ, PAUL ERICH (DMD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:ERICH
Last Name:ORTIZ
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 1:2525 NE BROADWAY ST STE 200
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1635
Mailing Address - Country:US
Mailing Address - Phone:503-234-7870
Mailing Address - Fax:503-236-9001
Practice Address - Street 1:2525 NE BROADWAY ST STE 200
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1635
Practice Address - Country:US
Practice Address - Phone:503-234-7870
Practice Address - Fax:503-236-9001
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR55661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR931165902OtherTAX ID #
OR5566OtherLICENSE #