Provider Demographics
NPI:1588404982
Name:ANDERSEN, GREGORY LOUIS (RDH)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:LOUIS
Last Name:ANDERSEN
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:MR
Other - First Name:GREG
Other - Middle Name:LOUIS
Other - Last Name:ANDERSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RDH
Mailing Address - Street 1:1776 SW MADISON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1715
Mailing Address - Country:US
Mailing Address - Phone:503-224-1044
Mailing Address - Fax:503-621-2235
Practice Address - Street 1:12750 SE STARK ST BLDG E
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1539
Practice Address - Country:US
Practice Address - Phone:971-347-3009
Practice Address - Fax:971-256-3277
Is Sole Proprietor?:No
Enumeration Date:2024-05-31
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH8136124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist