Provider Demographics
NPI:1518699263
Name:LACOSTE, AMY NICOLE (DMD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:NICOLE
Last Name:LACOSTE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:NICOLE
Other - Last Name:SCHLEHOFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:4815 SW LOMBARD AVE APT 427
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-3061
Mailing Address - Country:US
Mailing Address - Phone:916-532-2690
Mailing Address - Fax:
Practice Address - Street 1:2730 S MOODY AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-5042
Practice Address - Country:US
Practice Address - Phone:503-494-8867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-29
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD11898122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty