Provider Demographics
NPI:1619255809
Name:RAWLEY, ANGIE AGNES (DMD)
Entity Type:Individual
Prefix:DR
First Name:ANGIE
Middle Name:AGNES
Last Name:RAWLEY
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 1:2458 SE BURNSIDE RD
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97080-1247
Mailing Address - Country:US
Mailing Address - Phone:503-666-8045
Mailing Address - Fax:
Practice Address - Street 1:2458 SE BURNSIDE RD
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97080-1247
Practice Address - Country:US
Practice Address - Phone:503-666-8045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-22
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9622122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist