Healthcare Provider Details

I. General information

NPI: 1063966356
Provider Name (Legal Business Name): HEATHER MANKA DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2016
Last Update Date: 01/29/2025
Certification Date: 01/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9605 GRAND RONDE RD
GRAND RONDE OR
97347-9712
US

IV. Provider business mailing address

9605 GRAND RONDE RD
GRAND RONDE OR
97347-9712
US

V. Phone/Fax

Practice location:
  • Phone: 503-879-2020
  • Fax: 503-879-2071
Mailing address:
  • Phone: 503-879-2020
  • Fax: 503-879-2071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD10508
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: