Provider Demographics
NPI:1689006439
Name:PRUETT, AMY KATHLEEN (DMD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:KATHLEEN
Last Name:PRUETT
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:855-433-6825
Mailing Address - Fax:
Practice Address - Street 1:220 NE WEIDLER ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1121
Practice Address - Country:US
Practice Address - Phone:855-433-6825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-04
Last Update Date:2017-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9934122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
D9934OtherOREGON DENTAL LICENSE
1689006439OtherNPI