Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | H1361 | OR |
NPI | 1083029078 |
---|---|
Provider Name | Rosalyce Lucile Rose |
First Address | Reedsport, OR 97467-1746 |
Second Address | Reedsport, OR 97467-1373 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/06/2014 |
Last Update Date | 27/06/2014 |