Provider Demographics
NPI:1700313871
Name:HEABERLIN, CLIFFORD DANIEL
Entity type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:DANIEL
Last Name:HEABERLIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4211 N MISSISSIPPI AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-3132
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9775 SE SUNNYSIDE RD STE 200
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-5721
Practice Address - Country:US
Practice Address - Phone:503-655-8471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-18
Last Update Date:2017-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD107061223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program