Provider Demographics
NPI:1407100233
Name:BYWATERS, CODY MERRIL (LICENSED DENTURIST)
Entity Type:Individual
Prefix:MR
First Name:CODY
Middle Name:MERRIL
Last Name:BYWATERS
Suffix:
Gender:M
Credentials:LICENSED DENTURIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 DOUGLAS WAY
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-3446
Mailing Address - Country:US
Mailing Address - Phone:503-635-8060
Mailing Address - Fax:503-305-8679
Practice Address - Street 1:3900 DOUGLAS WAY
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-3446
Practice Address - Country:US
Practice Address - Phone:503-635-8060
Practice Address - Fax:503-305-8679
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-31
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDTDO10126042122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORDTDO 10126042OtherDENTURIST HEALTH LICENSE STATE OF OREGON