Provider Demographics
NPI:1427061415
Name:TRYBOM, MISTY HAUNANI (DDS)
Entity type:Individual
Prefix:DR
First Name:MISTY
Middle Name:HAUNANI
Last Name:TRYBOM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11907 SW LAUSANNE ST
Mailing Address - Street 2:
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-7328
Mailing Address - Country:US
Mailing Address - Phone:503-482-5071
Mailing Address - Fax:
Practice Address - Street 1:2300 LANCASTER DR NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1223
Practice Address - Country:US
Practice Address - Phone:503-370-4313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD86171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice