Provider Demographics
NPI:1467455360
Name:MUTSCHLER, MARK (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:MUTSCHLER
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13908 SE STARK ST
Mailing Address - Street 2:STE C
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-2161
Mailing Address - Country:US
Mailing Address - Phone:503-254-5535
Mailing Address - Fax:
Practice Address - Street 1:13908 SE STARK ST
Practice Address - Street 2:STE C
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-2161
Practice Address - Country:US
Practice Address - Phone:503-254-5535
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD69961223P0221X, 1223X0400X
CA38336122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1223P0221XDental ProvidersDentistPediatric Dentistry
Not Answered1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Not Answered122300000XDental ProvidersDentist