Provider Demographics
NPI:1104229004
Name:DEAN, JUSTIN WADE (DC)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:WADE
Last Name:DEAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2224 NE 142ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-3920
Mailing Address - Country:US
Mailing Address - Phone:503-995-3874
Mailing Address - Fax:
Practice Address - Street 1:3942 SE HAWTHORNE BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-5242
Practice Address - Country:US
Practice Address - Phone:503-235-5484
Practice Address - Fax:503-235-3956
Is Sole Proprietor?:No
Enumeration Date:2014-10-06
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5589111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor