Provider Demographics
NPI:1265432025
Name:DIERKS, ERIC J (MD, DMD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:J
Last Name:DIERKS
Suffix:
Gender:M
Credentials:MD, DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1849 NW KEARNEY ST
Mailing Address - Street 2:STE 300
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-1453
Mailing Address - Country:US
Mailing Address - Phone:503-224-1371
Mailing Address - Fax:503-224-0722
Practice Address - Street 1:1849 NW KEARNEY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209
Practice Address - Country:US
Practice Address - Phone:503-224-1371
Practice Address - Fax:503-224-0722
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD6708204E00000X
ORMD16391204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR008560Medicaid
OR008560Medicaid
OR00WCKCGBMedicare ID - Type Unspecified