Provider Demographics
NPI:1356598866
Name:KROKUM, RICHARD HENRY (DMD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:HENRY
Last Name:KROKUM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14205 SW ALLEN BLVD
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-4406
Mailing Address - Country:US
Mailing Address - Phone:503-646-7145
Mailing Address - Fax:503-646-7146
Practice Address - Street 1:14205 SW ALLEN BLVD
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-4406
Practice Address - Country:US
Practice Address - Phone:503-646-7145
Practice Address - Fax:503-646-7146
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-26
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4337122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist