Healthcare Provider Details

I. General information

NPI: 1073653788
Provider Name (Legal Business Name): JUDY WELLINGTON SYMONS RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10209 SE SUNNYSIDE RD
CLACKAMAS OR
97015-9782
US

IV. Provider business mailing address

10770 SE STEVENS WAY
PORTLAND OR
97266-7430
US

V. Phone/Fax

Practice location:
  • Phone: 503-353-3900
  • Fax:
Mailing address:
  • Phone: 503-659-1767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number1741
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: