Provider Demographics
NPI:1912394578
Name:MIKKELSON, AUDREY MICHELLE (DMD, MSD)
Entity Type:Individual
Prefix:DR
First Name:AUDREY
Middle Name:MICHELLE
Last Name:MIKKELSON
Suffix:
Gender:F
Credentials:DMD, MSD
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:MICHELLE
Other - Last Name:RIESEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:28236 SW WAGNER ST
Mailing Address - Street 2:
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-6784
Mailing Address - Country:US
Mailing Address - Phone:503-975-5001
Mailing Address - Fax:
Practice Address - Street 1:3745 PORTLAND RD NE STE 190
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-0529
Practice Address - Country:US
Practice Address - Phone:971-232-5858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-22
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD104841223P0221X, 1223G0001X
WADE611688471223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223P0221XDental ProvidersDentistPediatric Dentistry