Healthcare Provider Details

I. General information

NPI: 1124645437
Provider Name (Legal Business Name): RAMONA ANN WAITS DENTAL ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2020
Last Update Date: 07/02/2020
Certification Date: 07/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 NE 8TH ST
GRESHAM OR
97030-7317
US

IV. Provider business mailing address

600 NE 8TH ST
GRESHAM OR
97030-7317
US

V. Phone/Fax

Practice location:
  • Phone: 503-988-4900
  • Fax:
Mailing address:
  • Phone: 503-988-4900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number112756
License Number StateOR

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: