Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 204E00000X | Oral & Maxillofacial Surgeon | D6708 | OR |
Y | 204E00000X | Oral & Maxillofacial Surgeon | MD16391 | OR |
NPI | 1265432025 |
---|---|
Provider Name | Eric J Dierks |
First Address | Portland, OR 97209-1453 |
Second Address | Portland, OR 97209 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/07/2005 |
Last Update Date | 11/06/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
008560 | (05) | OR |
C15256 | (02) | OR |