Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | H2787 | OR |
NPI | 1003828203 |
---|---|
Provider Name | Mary Michelle Wade |
First Address | Silverton, OR 97381-9469 |
Second Address | Salem, OR 97305-1223 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/08/2006 |
Last Update Date | 08/07/2007 |