Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | 114785 | OR |
NPI | 1245728427 |
---|---|
Provider Name | Kerri Logue |
First Address | Battle Ground, WA 98604-2921 |
Second Address | Portland, OR 97217-5523 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/04/2018 |
Last Update Date | 24/04/2018 |