Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | H6587 | OR |
NPI | 1033581095 |
---|---|
Provider Name | Mandy Wengert |
First Address | Winchester, OR 97495-8935 |
Second Address | Roseburg, OR 97471-1281 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/10/2015 |
Last Update Date | 29/10/2015 |