MEDICARE: DR. ETIENNE LACRAMPE D.M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0300X	Periodontics	58771	CA

General Provider Information

NPI Number	:	1952529661
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ETIENNE LACRAMPE D.M.D.

Provider Business Mailing Address
First Line	:	11982 NE GLISAN ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97220-2143
Country	:	US
Telephone Number	:	503-257-8787
Fax Number	:

Provider Business Practice Location Address
First Line	:	1844 SAN MIGUEL DR STE 209
Second Line	:
City	:	WALNUT CREEK
State	:	CA
Zip	:	94596-4913
Country	:	US
Telephone Number	:	925-937-6350
Fax Number	:	925-937-6352

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/20/2007
Last Update Date	:	10/22/2021

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