Provider Demographics
NPI:1285629766
Name:PACKHAM, KEVIN REED (DMD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:REED
Last Name:PACKHAM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2403 SE MONROE ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-7646
Mailing Address - Country:US
Mailing Address - Phone:503-654-5995
Mailing Address - Fax:503-653-0465
Practice Address - Street 1:2403 SE MONROE ST
Practice Address - Street 2:SUITE C
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-7646
Practice Address - Country:US
Practice Address - Phone:503-654-5995
Practice Address - Fax:503-653-0465
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD71961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice