Provider Demographics
NPI:1780569681
Name:TRUONG, MICHAELYN VAN (DMD)
Entity type:Individual
Prefix:
First Name:MICHAELYN
Middle Name:VAN
Last Name:TRUONG
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 1:3602 S CORBETT AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4329
Mailing Address - Country:US
Mailing Address - Phone:503-902-2556
Mailing Address - Fax:
Practice Address - Street 1:3514 NE BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1821
Practice Address - Country:US
Practice Address - Phone:503-284-1602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-08
Last Update Date:2025-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD122391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice