Provider Demographics
NPI:1609088665
Name:ZYCHLA, MIROSLAW ANTONI (DENTURIST)
Entity Type:Individual
Prefix:
First Name:MIROSLAW
Middle Name:ANTONI
Last Name:ZYCHLA
Suffix:
Gender:M
Credentials:DENTURIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6207 LOUISIANA DR
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-7521
Mailing Address - Country:US
Mailing Address - Phone:360-696-4265
Mailing Address - Fax:
Practice Address - Street 1:6950 NE CAMPUS WAY
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-5611
Practice Address - Country:US
Practice Address - Phone:800-460-7644
Practice Address - Fax:503-952-2264
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDT-DO-163846122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist