Healthcare Provider Details

I. General information

NPI: 1588771885
Provider Name (Legal Business Name): ALISA ANN PROUDFOOT R.D.H.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALISA ANN SEGER R.D.H.

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 07/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4855 SW WESTERN AVE
BEAVERTON OR
97005-3460
US

IV. Provider business mailing address

4855 SW WESTERN AVE
BEAVERTON OR
97005-3460
US

V. Phone/Fax

Practice location:
  • Phone: 503-626-4148
  • Fax: 503-626-4412
Mailing address:
  • Phone: 503-626-4148
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH2484
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: