Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | D10027 | OR |
NPI | 1003256827 |
---|---|
Provider Name | Dr. Octavia S Lively |
First Address | Portland, OR 97239-2964 |
Second Address | Portland, OR 97239-2964 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/06/2013 |
Last Update Date | 12/02/2019 |