Healthcare Provider Details

I. General information

NPI: 1053600148
Provider Name (Legal Business Name): KARLENE A MARTIN RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2011
Last Update Date: 03/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3465 NW CIRCLE BLVD
CORVALLIS OR
97330-1759
US

IV. Provider business mailing address

3465 NW CIRCLE BLVD
CORVALLIS OR
97330-1759
US

V. Phone/Fax

Practice location:
  • Phone: 541-757-0175
  • Fax:
Mailing address:
  • Phone: 541-757-0175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH3094
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: