Provider Demographics
NPI:1942609383
Name:AMICO, ELIZABETH (DMD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:AMICO
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 1:2433 NW LOVEJOY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-3023
Mailing Address - Country:US
Mailing Address - Phone:503-507-3588
Mailing Address - Fax:
Practice Address - Street 1:324 SW 7TH ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-4992
Practice Address - Country:US
Practice Address - Phone:503-507-3588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-21
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH6799124Q00000X
ORD12051122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORD12051OtherOREGON BOARD OF DENTISTRY