Derek Conklin, D.M.D.
Individual provider Active NPI Dentist · Sandy, OR
NPI 1396868048 · NPPES record last updated Feb 28, 2012
Key facts
- NPI
- 1396868048
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Dentist 122300000X
- License
- D8325 (OR)
- Practice address
- 17471 Shelley Ave Ste a
Sandy, OR 97055-8084 - Phone
- (503) 668-4655
- Fax
- (503) 668-8755
- NPI assigned
- Apr 9, 2007
- Sex
- Male
- Sole proprietor
- Yes
Organizations & group practices 1
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in OR
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: No · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20150818004927 | OR | Order and Referring Only - Oral Surgery |
3476868506 |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Derek W. Conklin DMD PC | Dentist | Past | Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | D8325 | OR | Yes |
Addresses
Primary practice location
17471 Shelley Ave Ste a
Sandy, OR 97055-8084
Mailing address
17471 Shelley Ave
Sandy, OR 97055-8084
Phone (503) 668-4655
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 243185 | Medicaid | OR |
Other providers in Sandy, OR
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Feb 28, 2012. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.