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NPI Code Detail

MEDICARE: CARLY K CHRISTOFERSON DMD PC

MEDICARE: CARLY K CHRISTOFERSON DMD PC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1261QD0000XDental Clinic/Center

General Provider Information

NPI Number : 1548917321
Entity Type Code : Organization
Provider Name (Legal Business Name) : CARLY K CHRISTOFERSON DMD PC
Provider Business Mailing Address
First Line : 3900 DOUGLAS WAY
Second Line :
City : LAKE OSWEGO
State : OR
Zip : 97035-3446
Country : US
Telephone Number : 503-636-8446
Fax Number : 503-636-4446
Provider Business Practice Location Address
First Line : 3900 DOUGLAS WAY
Second Line :
City : LAKE OSWEGO
State : OR
Zip : 97035-3446
Country : US
Telephone Number : 503-636-8446
Fax Number : 503-636-4446
Authorized Official
Title or Position : PRESIDENT
Name : CARLY CHRISTOFERSON PETERSEN
Credential : DMD
Telephone Number : 503-758-8174
Provider Enumeration Date : 03/02/2022
Last Update Date : 03/02/2022

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