Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 124Q00000X | Dental Hygienist | ||
Y | 124Q00000X | Dental Hygienist | H4563 | OR |
NPI | 1033634100 |
---|---|
Provider Name | Mrs. Oma Casandra Hampton |
First Address | Portland, OR 97211-4081 |
Second Address | Portland, OR 97211-4081 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/08/2017 |
Last Update Date | 09/08/2017 |