Provider Demographics
NPI:1407936107
Name:KOHNKE, WASHINGTON I (DMD)
Entity Type:Individual
Prefix:
First Name:WASHINGTON
Middle Name:I
Last Name:KOHNKE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:W
Other - Middle Name:I
Other - Last Name:KOHNKE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD LLC
Mailing Address - Street 1:601 FIRST ST
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-2328
Mailing Address - Country:US
Mailing Address - Phone:503-636-2300
Mailing Address - Fax:503-635-6682
Practice Address - Street 1:601 FIRST ST
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97034-2328
Practice Address - Country:US
Practice Address - Phone:503-636-2300
Practice Address - Fax:503-635-6682
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD47401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice