Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | 117418 | OR |
NPI | 1285264036 |
---|---|
Provider Name | Kelsey Tate |
First Address | Beaverton, OR 97005-1401 |
Second Address | Beaverton, OR 97005-1401 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/01/2020 |
Last Update Date | 21/01/2020 |