Provider Demographics
NPI:1235332834
Name:PETRISOR, DANIEL (DMD, MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:PETRISOR
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-494-8916
Mailing Address - Fax:503-494-6783
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-8916
Practice Address - Fax:503-494-6783
Is Sole Proprietor?:No
Enumeration Date:2007-06-09
Last Update Date:2025-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD154906204E00000X, 204E00000X
ORD90591223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL148H9OtherBCBS FL
FL0022923-00Medicaid
OR500651136Medicaid
OR500654224Medicaid
BP1-0026540OtherINSTITUTIONAL PERMIT
ORR168529Medicare PIN
OR500651136Medicaid