Provider Demographics
NPI:1801017033
Name:VERNWALD, BEVERLY (LD)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:VERNWALD
Suffix:
Gender:F
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7121 N SWIFT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-1368
Mailing Address - Country:US
Mailing Address - Phone:503-289-5862
Mailing Address - Fax:
Practice Address - Street 1:2905 SE OAK GROVE BLVD
Practice Address - Street 2:SUITE 3
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97267-1300
Practice Address - Country:US
Practice Address - Phone:503-654-4583
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDTDO694389122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist