Provider Demographics
NPI:1619025996
Name:WROLSTAD, AMITY M (DMD)
Entity Type:Individual
Prefix:DR
First Name:AMITY
Middle Name:M
Last Name:WROLSTAD
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6950 NE CAMPUS WAY
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-5611
Mailing Address - Country:US
Mailing Address - Phone:503-952-2125
Mailing Address - Fax:
Practice Address - Street 1:2420 NW PROFESSIONAL DR
Practice Address - Street 2:SUITE 150
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-3990
Practice Address - Country:US
Practice Address - Phone:541-758-6587
Practice Address - Fax:541-758-6768
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD8653122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist