Provider Demographics
NPI:1942427216
Name:HERRIGES, BROCK D (DMD)
Entity type:Individual
Prefix:DR
First Name:BROCK
Middle Name:D
Last Name:HERRIGES
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 1:1130 SE 122ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-1112
Mailing Address - Country:US
Mailing Address - Phone:503-252-5515
Mailing Address - Fax:503-255-1625
Practice Address - Street 1:1130 SE 122ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1112
Practice Address - Country:US
Practice Address - Phone:503-252-5515
Practice Address - Fax:503-255-1625
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD83711223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics