Healthcare Provider Details

I. General information

NPI: 1609217520
Provider Name (Legal Business Name): FAREN GABRIELLE CALDWELL RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2013
Last Update Date: 07/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 NE BURNSIDE
GRESHAM OR
97030-5710
US

IV. Provider business mailing address

1107 NE BURNSIDE
GRESHAM OR
97030-5710
US

V. Phone/Fax

Practice location:
  • Phone: 360-608-2665
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH6334
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH60304580
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: