Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | 930798039 | OR |
NPI | 1336703198 |
---|---|
Provider Name | Vanessa Joan Grant |
First Address | Portland, OR 97217-5523 |
Second Address | Portland, OR 97217-5523 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/04/2019 |
Last Update Date | 26/04/2019 |