Healthcare Provider Details

I. General information

NPI: 1619025996
Provider Name (Legal Business Name): AMITY M WROLSTAD DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 04/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 NW PROFESSIONAL DR SUITE 150
CORVALLIS OR
97330-3990
US

IV. Provider business mailing address

6950 NE CAMPUS WAY
HILLSBORO OR
97124-5611
US

V. Phone/Fax

Practice location:
  • Phone: 541-758-6587
  • Fax: 541-758-6768
Mailing address:
  • Phone: 503-952-2125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD8653
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: