Provider Demographics
NPI:1811625569
Name:HRYCIW, GWEN M (DMD, PHD)
Entity type:Individual
Prefix:
First Name:GWEN
Middle Name:M
Last Name:HRYCIW
Suffix:
Gender:F
Credentials:DMD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14820 NW RIDGETOP CT
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-5404
Mailing Address - Country:US
Mailing Address - Phone:503-888-8966
Mailing Address - Fax:
Practice Address - Street 1:15125 SW BEARD RD
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97007-7477
Practice Address - Country:US
Practice Address - Phone:503-590-4300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-10
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD116671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty