Basic Information
| Provider Information | |||||||||
| NPI: | 1689006439 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRUETT | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | KATHLEEN | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6950 NE CAMPUS WAY | ||||||||
| Address2: | |||||||||
| City: | HILLSBORO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971245611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8554336825 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 220 NE WEIDLER ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972321121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8554336825 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2013 | ||||||||
| LastUpdateDate: | 09/18/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | D9934 | OR | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | D9934 | 01 | OREGON DENTAL LICENSE | OTHER | 1689006439 | 01 | NPI | OTHER |