Healthcare Provider Details

I. General information

NPI: 1306037908
Provider Name (Legal Business Name): JONALEE COZAKOS POTTER RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2007
Last Update Date: 02/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 N 11TH AVE
CORNELIUS OR
97113-9020
US

IV. Provider business mailing address

PO BOX 6149
BEAVERTON OR
97007-0149
US

V. Phone/Fax

Practice location:
  • Phone: 503-359-8505
  • Fax: 503-434-8597
Mailing address:
  • Phone: 503-359-8501
  • Fax: 503-434-8597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number111930-9920
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH-1678
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberHL00007676
License Number StateWA
# 4
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH1907
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: