Healthcare Provider Details

I. General information

NPI: 1609088665
Provider Name (Legal Business Name): MIROSLAW ANTONI ZYCHLA DENTURIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6950 NE CAMPUS WAY
HILLSBORO OR
97124-5611
US

IV. Provider business mailing address

6207 LOUISIANA DR
VANCOUVER WA
98661-7521
US

V. Phone/Fax

Practice location:
  • Phone: 800-460-7644
  • Fax: 503-952-2264
Mailing address:
  • Phone: 360-696-4265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License NumberDT-DO-163846
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: