Provider Demographics
NPI:1851694640
Name:MAYERLE, BRAD A (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRAD
Middle Name:A
Last Name:MAYERLE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:BRAD
Other - Middle Name:A
Other - Last Name:MAYERLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:14800 KRUSE OAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-8603
Mailing Address - Country:US
Mailing Address - Phone:503-684-2944
Mailing Address - Fax:503-624-6335
Practice Address - Street 1:14800 KRUSE OAKS BLVD
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-8603
Practice Address - Country:US
Practice Address - Phone:503-684-2944
Practice Address - Fax:503-624-6335
Is Sole Proprietor?:No
Enumeration Date:2010-12-16
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD68961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice