Healthcare Provider Details

I. General information

NPI: 1124465372
Provider Name (Legal Business Name): NORTHWEST MOBILE HYGIENE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2013
Last Update Date: 05/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20392 SW BLAINE CT
ALOHA OR
97006-2115
US

IV. Provider business mailing address

PO BOX 7014
ALOHA OR
97007-7014
US

V. Phone/Fax

Practice location:
  • Phone: 503-440-2313
  • Fax:
Mailing address:
  • Phone: 503-440-2313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH6359
License Number StateOR

VIII. Authorized Official

Name: MRS. ROBIN WENDY FATAFEHI
Title or Position: REGISTERED DENTAL HYGIENIST
Credential: RDH, BS, EPDH
Phone: 503-440-2313