Provider Demographics
NPI:1255492831
Name:MONROE, MIKE L (DMD PC)
Entity Type:Individual
Prefix:DR
First Name:MIKE
Middle Name:L
Last Name:MONROE
Suffix:
Gender:M
Credentials:DMD PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1133 NW 11TH AVE APT 709
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-3089
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3835 SW 185TH AVE STE 400
Practice Address - Street 2:
Practice Address - City:ALOHA
Practice Address - State:OR
Practice Address - Zip Code:97007-1553
Practice Address - Country:US
Practice Address - Phone:503-642-2540
Practice Address - Fax:503-591-9846
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR45351223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics