Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant |
NPI | 1043365919 |
---|---|
Provider Name | Mrs. Heidi Vanessa Johnson |
First Address | Portland, OR 97268-1183 |
Second Address | Clackamas, OR 97015-9782 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/01/2007 |
Last Update Date | 08/07/2007 |