Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | H5875 | OR |
NPI | 1073850137 |
---|---|
Provider Name | Jeni Wilson |
First Address | Beaverton, OR 97007-4933 |
Second Address | Hillsboro, OR 97123-8575 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/01/2013 |
Last Update Date | 09/01/2013 |