Provider Demographics
NPI:1295143212
Name:GERRITZ, DALLAS MICHAEL (DMD)
Entity type:Individual
Prefix:DR
First Name:DALLAS
Middle Name:MICHAEL
Last Name:GERRITZ
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 1:1600 SW CEDAR HILLS BLVD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-5439
Mailing Address - Country:US
Mailing Address - Phone:503-643-7502
Mailing Address - Fax:
Practice Address - Street 1:1600 SW CEDAR HILLS BLVD
Practice Address - Street 2:SUITE 107
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5439
Practice Address - Country:US
Practice Address - Phone:503-643-7502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-23
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD100881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice