Provider Demographics
NPI:1982684809
Name:PLUNKETT, MICHAEL L (DDS, MPH)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:PLUNKETT
Suffix:
Gender:M
Credentials:DDS, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 SW CAMPUS DRIVE
Mailing Address - Street 2:DEPARTMENT OF COMMUNITY DENTISTRY, SCHOOL OF DENTISTRY
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3097
Mailing Address - Country:US
Mailing Address - Phone:503-494-0566
Mailing Address - Fax:503-494-8839
Practice Address - Street 1:214 N. RUSSELL STREET
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227
Practice Address - Country:US
Practice Address - Phone:503-494-0566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD8894122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0239651Medicaid