Basic Information
| Provider Information | |||||||||
| NPI: | 1700313871 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEABERLIN | ||||||||
| FirstName: | CLIFFORD | ||||||||
| MiddleName: | DANIEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4211 N MISSISSIPPI AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972173132 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 9775 SE SUNNYSIDE RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | CLACKAMAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970155721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036558471 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2017 | ||||||||
| LastUpdateDate: | 07/27/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | D10706 | OR | Y | Dental Providers | Dentist | General Practice | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.