Healthcare Provider Details

I. General information

NPI: 1134476674
Provider Name (Legal Business Name): JEREMY HUTTNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2012
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9775 SE SUNNYSIDE RD STE 200
CLACKAMAS OR
97015-5721
US

IV. Provider business mailing address

9775 SE SUNNYSIDE RD
CLACKAMAS OR
97015-5739
US

V. Phone/Fax

Practice location:
  • Phone: 503-655-8471
  • Fax:
Mailing address:
  • Phone: 503-655-8471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD10734
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: