Healthcare Provider Details

I. General information

NPI: 1912004276
Provider Name (Legal Business Name): MRS. PATRICE M FOOTE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4855 SW WESTERN AVE
BEAVERTON OR
97005
US

IV. Provider business mailing address

11610 NW ROCK CRK RD
PORTLAND OR
97231
US

V. Phone/Fax

Practice location:
  • Phone: 503-626-4148
  • Fax:
Mailing address:
  • Phone: 503-645-0204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: