Provider Demographics
NPI:1669583472
Name:EVERETT, ROBERT HIGHLEY
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:HIGHLEY
Last Name:EVERETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ROBERT
Other - Middle Name:
Other - Last Name:EVERETT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:325 PORTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:OR
Mailing Address - Zip Code:97027-2450
Mailing Address - Country:US
Mailing Address - Phone:503-656-8426
Mailing Address - Fax:
Practice Address - Street 1:325 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:OR
Practice Address - Zip Code:97027-2450
Practice Address - Country:US
Practice Address - Phone:503-656-8426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD5777122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORD5777OtherSTATE LICENSE NUMBER