Provider Demographics
NPI:1396868048
Name:CONKLIN, DEREK (DMD)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:
Last Name:CONKLIN
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 1:17471 SHELLEY AVE
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:OR
Mailing Address - Zip Code:97055-8084
Mailing Address - Country:US
Mailing Address - Phone:503-668-4655
Mailing Address - Fax:503-668-8755
Practice Address - Street 1:17471 SHELLEY AVE STE A
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:OR
Practice Address - Zip Code:97055-8084
Practice Address - Country:US
Practice Address - Phone:503-668-4655
Practice Address - Fax:503-668-8755
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD8325122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR243185Medicaid