Healthcare Provider Details

I. General information

NPI: 1326104076
Provider Name (Legal Business Name): KENNETH MARNE STINCHFIELD DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 04/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 SE 133RD AVE
PORTLAND OR
97233-1809
US

IV. Provider business mailing address

6950 NE CAMPUS WAY
HILLSBORO OR
97124-5611
US

V. Phone/Fax

Practice location:
  • Phone: 503-255-7188
  • Fax: 503-261-0971
Mailing address:
  • Phone: 503-952-2125
  • Fax: 503-526-4418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD8179
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDE00005871
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD-3945-OS
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: