Provider Demographics
NPI:1386794626
Name:LAIRD, CARRIE BULLACK (DMD)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:BULLACK
Last Name:LAIRD
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 1:2275 GLEN HAVEN ROAD
Mailing Address - Street 2:
Mailing Address - City:LAKE OWESGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034
Mailing Address - Country:US
Mailing Address - Phone:971-998-6383
Mailing Address - Fax:
Practice Address - Street 1:15125 SW BEARD ROAD
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97007
Practice Address - Country:US
Practice Address - Phone:503-590-4300
Practice Address - Fax:503-590-0269
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR87671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice