Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | H5720 | OR |
NPI | 1063870095 |
---|---|
Provider Name | Krista Moore |
First Address | Tigard, OR 97223-8314 |
Second Address | Portland, OR 97230-1003 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/02/2016 |
Last Update Date | 25/02/2016 |