Healthcare Provider Details

I. General information

NPI: 1255997235
Provider Name (Legal Business Name): CHRISTOPHER PETER MCCARTHY LD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2019
Last Update Date: 02/25/2022
Certification Date: 02/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 NE 20TH AVE STE 100
PORTLAND OR
97232-3094
US

IV. Provider business mailing address

200 NE 20TH AVE STE 100
PORTLAND OR
97232-3094
US

V. Phone/Fax

Practice location:
  • Phone: 503-230-0207
  • Fax:
Mailing address:
  • Phone: 503-230-0207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License NumberDT-DO-10198679
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: