Provider Demographics
NPI:1104823111
Name:SELIS, RONALD CHARLES (DMD, PC)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:CHARLES
Last Name:SELIS
Suffix:
Gender:M
Credentials:DMD, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2422 NE FREMONT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-2509
Mailing Address - Country:US
Mailing Address - Phone:503-287-1554
Mailing Address - Fax:503-280-8773
Practice Address - Street 1:2422 NE FREMONT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-2509
Practice Address - Country:US
Practice Address - Phone:503-287-1554
Practice Address - Fax:503-280-8773
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD65821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice