Provider Demographics
NPI:1710128202
Name:MOHR, MARY KELLY (DDS)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KELLY
Last Name:MOHR
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 N RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1620
Mailing Address - Country:US
Mailing Address - Phone:503-494-6822
Mailing Address - Fax:503-284-1398
Practice Address - Street 1:214 N RUSSELL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1620
Practice Address - Country:US
Practice Address - Phone:503-494-6822
Practice Address - Fax:503-284-1398
Is Sole Proprietor?:No
Enumeration Date:2009-03-13
Last Update Date:2009-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR8778122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist