Healthcare Provider Details

I. General information

NPI: 1073607115
Provider Name (Legal Business Name): CAROLYN ANN MUCKERHEIDE D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2380 NW AMBERBROOK DR
HILLSBORO OR
97006-6952
US

IV. Provider business mailing address

2380 NW AMBERBROOK DR
HILLSBORO OR
97006-6952
US

V. Phone/Fax

Practice location:
  • Phone: 503-641-8800
  • Fax: 503-352-0721
Mailing address:
  • Phone: 503-641-8800
  • Fax: 503-352-0721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberD8526
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: