Healthcare Provider Details

I. General information

NPI: 1821519505
Provider Name (Legal Business Name): JAIME ELLEN HOLTZ DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

387 NE 223RD AVE
GRESHAM OR
97030-8554
US

IV. Provider business mailing address

387 NE 223RD AVE
GRESHAM OR
97030-8554
US

V. Phone/Fax

Practice location:
  • Phone: 503-491-5450
  • Fax:
Mailing address:
  • Phone: 503-491-5450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD10659
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: