Basic Information
Provider Information | |||||||||
NPI: | 1477623122 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PARKER | ||||||||
FirstName: | PATRICIA | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DMD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6950 NE CAMPUS WAY | ||||||||
Address2: |   | ||||||||
City: | HILLSBORO | ||||||||
State: | OR | ||||||||
PostalCode: | 971245611 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5039522164 | ||||||||
FaxNumber: | 5035264418 | ||||||||
Practice Location | |||||||||
Address1: | 2225 PACIFIC BLVD SE | ||||||||
Address2: | SUITE 201 | ||||||||
City: | ALBANY | ||||||||
State: | OR | ||||||||
PostalCode: | 973217907 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5419284300 | ||||||||
FaxNumber: | 5419289958 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/09/2006 | ||||||||
LastUpdateDate: | 05/21/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | D6295 | OR | Y |   | Dental Providers | Dentist |   |
ID Information
ID | Type | State | Issuer | Description | 136903 | 01 | OR | OREGON HEALTH PLAN | OTHER |