Healthcare Provider Details

I. General information

NPI: 1063961977
Provider Name (Legal Business Name): DUSTY LAWELLIN RDH, EP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2016
Last Update Date: 10/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2260 SW 3RD ST
CORVALLIS OR
97333-1745
US

IV. Provider business mailing address

2260 SW 3RD ST
CORVALLIS OR
97333-1745
US

V. Phone/Fax

Practice location:
  • Phone: 503-917-4221
  • Fax:
Mailing address:
  • Phone: 503-917-4221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH7259
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: