Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | H6437 | OR |
NPI | 1073959946 |
---|---|
Provider Name | Jennifer Main |
First Address | Beaverton, OR 97005-8728 |
Second Address | Beaverton, OR 97005-8728 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/05/2013 |
Last Update Date | 03/02/2014 |