Healthcare Provider Details

I. General information

NPI: 1881771103
Provider Name (Legal Business Name): MR. KARL JOHAN PFALZGRAFF
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7105 SW HAMPTON ST
TIGARD OR
97223-8314
US

IV. Provider business mailing address

1316 MADISON ST
OREGON CITY OR
97045-1461
US

V. Phone/Fax

Practice location:
  • Phone: 503-684-9274
  • Fax:
Mailing address:
  • Phone: 503-650-1367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number114055
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: