Provider Demographics
NPI:1780230599
Name:CLAGGETT, ETHAN YOSHIO (DMD)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:YOSHIO
Last Name:CLAGGETT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14088 SE EKLUND AVE
Mailing Address - Street 2:
Mailing Address - City:BORING
Mailing Address - State:OR
Mailing Address - Zip Code:97009-7035
Mailing Address - Country:US
Mailing Address - Phone:503-956-3845
Mailing Address - Fax:
Practice Address - Street 1:39055 PIONEER BLVD
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:OR
Practice Address - Zip Code:97055-8013
Practice Address - Country:US
Practice Address - Phone:503-668-7441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-16
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD111301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice