Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | H6377 | OR |
NPI | 1063899508 |
---|---|
Provider Name | Tracy Campos |
First Address | Aloha, OR 97003 |
Second Address | Aloha, OR 97003 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/05/2015 |
Last Update Date | 05/05/2015 |