Provider Demographics
NPI:1972172633
Name:WESTBERG, MITCHELL EDMUND (DDS)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:EDMUND
Last Name:WESTBERG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 HICKORY ST NW # A
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97321-1724
Mailing Address - Country:US
Mailing Address - Phone:541-928-1509
Mailing Address - Fax:
Practice Address - Street 1:155 HICKORY ST NW # A
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-1724
Practice Address - Country:US
Practice Address - Phone:541-928-1509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-17
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013658A122300000X
ORD11789122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist