Gary Theodore Pederson, D.D.S.

Primary specialty

Oral and Maxillofacial Surgery (Dentist)Taxonomy code 1223S0112X

License

D4658 Issued in OR

Practice address

1565 Liberty St SE
Salem, OR 97302-4345

Phone

(503) 581-0223

Fax

(503) 581-6794

NPI assigned

Jul 14, 2005

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Gary T. Pederson

  • Oral and Maxillofacial Surgery (Dentist)
  • Salem, OR
  • NPI 1154517415
  NPD (past) Authorized official
• Mid-Valley Oral, Maxillofacial & Implant Surgery

  • Oral and Maxillofacial Surgery Clinic/Center
  • Salem, OR
  • NPI 1386901734
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1121299200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1184630400000",
    "number": "1447258223",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1565 LIBERTY ST SE",
            "city": "SALEM",
            "state": "OR",
            "postal_code": "973024345",
            "telephone_number": "503-581-0223",
            "fax_number": "503-581-6794"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1565 LIBERTY ST SE",
            "city": "SALEM",
            "state": "OR",
            "postal_code": "973024345",
            "telephone_number": "503-581-0223",
            "fax_number": "503-581-6794"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PEDERSON",
        "first_name": "GARY",
        "middle_name": "THEODORE",
        "credential": "D.D.S.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2005-07-14",
        "last_updated": "2007-07-17",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "OR",
            "license": "D4658",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Kyle Pearson, M.D.
• Jamie Sue Pease, PA-C
• Maison Jarred Pebworth
• Steven Michael Peck, DMD
• Niels Frederik Pedersen, MD
• Pediatric Dental Associates of Salem
• Pediatric Dentistry of Salem LLC
• Pediatric Rehabilitation Northwest
• Peers for Love, Inc.
• Richard Peffley II, D.P.M.

• Oral and Maxillofacial Surgery (Dentist) in Salem, OR
• Providers in Salem, OR by specialty
• Oral and Maxillofacial Surgery (Dentist) in Oregon

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 17, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.