Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | OR |
NPI | 1164979704 |
---|---|
Provider Name | Jessicalin Brodo Ribellia |
First Address | Hillsboro, OR 97123-4686 |
Second Address | Hillsboro, OR 97123 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/09/2016 |
Last Update Date | 01/09/2016 |