Provider Demographics
NPI:1104249192
Name:HAVERCROFT, MANDY (BS, RDH)
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:
Last Name:HAVERCROFT
Suffix:
Gender:F
Credentials:BS, RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6965 SW NYBERG ST
Mailing Address - Street 2:#U203
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-7479
Mailing Address - Country:US
Mailing Address - Phone:503-881-0935
Mailing Address - Fax:
Practice Address - Street 1:10115 SW NIMBUS AVE
Practice Address - Street 2:#350
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-4349
Practice Address - Country:US
Practice Address - Phone:503-308-4073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-27
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH6480124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist