Provider Demographics
NPI:1386903938
Name:BRINK, PETER DJOPAIH (DMD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:DJOPAIH
Last Name:BRINK
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 1:3027 SE 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-2002
Mailing Address - Country:US
Mailing Address - Phone:503-729-5021
Mailing Address - Fax:
Practice Address - Street 1:8400 NE VANCOUVER MALL LOOP STE 105
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-6672
Practice Address - Country:US
Practice Address - Phone:360-839-2793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-15
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD108941223G0001X
WADE614871511223G0001X
CO00202036122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist