Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | H5788 | OR |
NPI | 1013254218 |
---|---|
Provider Name | Miss Sydney Marie Craven |
First Address | Siletz, OR 97380 |
Second Address | Siletz, OR 97380-9743 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 08/01/2013 |
Last Update Date | 08/01/2013 |