Healthcare Provider Details

I. General information

NPI: 1659660108
Provider Name (Legal Business Name): MARY ANN WREN B.S., RDH, LAP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2011
Last Update Date: 04/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2381 NE CONNERS AVE
BEND OR
97701-6068
US

IV. Provider business mailing address

2675 SW 49TH ST
REDMOND OR
97756-1160
US

V. Phone/Fax

Practice location:
  • Phone: 541-389-1704
  • Fax: 541-389-1705
Mailing address:
  • Phone: 541-975-3972
  • Fax: 541-389-1705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH5219
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: