Provider Demographics
NPI:1174794853
Name:GALLEGOS, AMANDA M (DMD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:M
Last Name:GALLEGOS
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 1:8225 SW TUALATIN SHERWOOD RD
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-8441
Mailing Address - Country:US
Mailing Address - Phone:503-692-9386
Mailing Address - Fax:
Practice Address - Street 1:8225 SW TUALATIN SHERWOOD RD
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-8441
Practice Address - Country:US
Practice Address - Phone:503-692-9386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-20
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD8622122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Yes122300000XDental ProvidersDentist