Provider Demographics
NPI:1275641284
Name:MALMQUIST, JAY PRESTON (DMD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:PRESTON
Last Name:MALMQUIST
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:5415 SW WESTGATE DR
Mailing Address - Street 2:SUITE #L-7
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97221-2409
Mailing Address - Country:US
Mailing Address - Phone:503-292-8824
Mailing Address - Fax:503-297-7810
Practice Address - Street 1:5415 SW WESTGATE DR
Practice Address - Street 2:SUITE #L-7
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97221-2409
Practice Address - Country:US
Practice Address - Phone:503-292-8824
Practice Address - Fax:503-297-7810
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD46421223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORT67870Medicare UPIN