Provider Demographics
NPI:1538776315
Name:STROM, KIRSTIN (DMD)
Entity type:Individual
Prefix:
First Name:KIRSTIN
Middle Name:
Last Name:STROM
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 1:2141 SW HARBOR PL
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-8021
Mailing Address - Country:US
Mailing Address - Phone:715-410-7230
Mailing Address - Fax:
Practice Address - Street 1:7017 SW NYBERG ST STE P-46
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-6243
Practice Address - Country:US
Practice Address - Phone:503-612-8736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-25
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD11337122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist