Basic Information
| Provider Information | |||||||||
| NPI: | 1902898307 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARLESIMO | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | DANIEL | ||||||||
| NamePrefix: | |||||||||
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| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 6950 NE CAMPUS WAY | ||||||||
| Address2: | |||||||||
| City: | HILLSBORO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971245611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8554336825 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3490 LANCASTER DR NE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973051356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8554336825 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2005 | ||||||||
| LastUpdateDate: | 10/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DE61007889 | WA | N | Dental Providers | Dentist | General Practice | 122300000X | D9514 | OR | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | D9514 | 01 | OR | DENTIST LICENSE | OTHER |