Healthcare Provider Details

I. General information

NPI: 1740626662
Provider Name (Legal Business Name): ABBY RAE EVESON R.D.H.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2013
Last Update Date: 12/22/2021
Certification Date: 12/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10209 SE SUNNYSIDE RD
CLACKAMAS OR
97015-9782
US

IV. Provider business mailing address

14300 SE 156TH AVE
CLACKAMAS OR
97015-6651
US

V. Phone/Fax

Practice location:
  • Phone: 800-813-2000
  • Fax:
Mailing address:
  • Phone: 503-810-4594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH5816
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: