Provider Demographics
NPI:1619504164
Name:GERLACH, ANNA NICOLE (DMD)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:NICOLE
Last Name:GERLACH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:ANNA
Other - Middle Name:NICOLE
Other - Last Name:HILDEBRAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:10500 SW BANNOCH CT
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-8400
Mailing Address - Country:US
Mailing Address - Phone:503-319-0541
Mailing Address - Fax:
Practice Address - Street 1:1915 NE BAKER ST
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-2601
Practice Address - Country:US
Practice Address - Phone:503-472-7121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-25
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD11212122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist