Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | 120494 | OR |
NPI | 1174944557 |
---|---|
Provider Name | Lisa Hardy |
First Address | Portland, OR 97266-5222 |
Second Address | Tigard, OR 97223-8314 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/01/2014 |
Last Update Date | 02/01/2014 |