Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | H7259 | OR |
NPI | 1063961977 |
---|---|
Provider Name | Dusty Lawellin |
First Address | Corvallis, OR 97333-1745 |
Second Address | Corvallis, OR 97333-1745 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/10/2016 |
Last Update Date | 04/10/2016 |