Provider Demographics
NPI:1619638764
Name:CARDULLO, MARY KAITLIN (DMD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KAITLIN
Last Name:CARDULLO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:KATE
Other - Middle Name:
Other - Last Name:CARDULLO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:1522 SE BELMONT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-2642
Mailing Address - Country:US
Mailing Address - Phone:304-651-0182
Mailing Address - Fax:
Practice Address - Street 1:8568 SW APPLE WAY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-1772
Practice Address - Country:US
Practice Address - Phone:503-292-6773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-31
Last Update Date:2021-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD11547122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist