Provider Demographics
NPI:1508855230
Name:CANTRELL, CAROLYN M (DMD)
Entity Type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:M
Last Name:CANTRELL
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 1:2233 WILLAMETTE ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405-2890
Mailing Address - Country:US
Mailing Address - Phone:541-687-2156
Mailing Address - Fax:541-684-9268
Practice Address - Street 1:2233 WILLAMETTE ST
Practice Address - Street 2:SUITE B
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97405-2890
Practice Address - Country:US
Practice Address - Phone:541-687-2156
Practice Address - Fax:541-684-9268
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD68771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR119524Medicaid