Provider Demographics
NPI:1952314460
Name:GYAPONG, FAY A (DMD)
Entity Type:Individual
Prefix:DR
First Name:FAY
Middle Name:A
Last Name:GYAPONG
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 SW 11TH AVE
Mailing Address - Street 2:SUITE 1015
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205
Mailing Address - Country:US
Mailing Address - Phone:503-224-4688
Mailing Address - Fax:503-224-5892
Practice Address - Street 1:833 SW 11TH AVE
Practice Address - Street 2:SUITE 1015
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205
Practice Address - Country:US
Practice Address - Phone:503-224-4688
Practice Address - Fax:503-224-5892
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2017-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD66761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR900417649OtherFEDERAL TIN