Healthcare Provider Details

I. General information

NPI: 1164772539
Provider Name (Legal Business Name): KYLE DENMARK RDH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2012
Last Update Date: 03/09/2022
Certification Date: 03/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10180 SE SUNNYSIDE RD
CLACKAMAS OR
97015-9303
US

IV. Provider business mailing address

3341 SE 112TH AVE
PORTLAND OR
97266
US

V. Phone/Fax

Practice location:
  • Phone: 503-571-6969
  • Fax:
Mailing address:
  • Phone: 503-898-0589
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH6297
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: