Healthcare Provider Details

I. General information

NPI: 1184812885
Provider Name (Legal Business Name): SHANNON VUYLSTEKE EFDA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2007
Last Update Date: 10/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19075 NW TANASBOURNE DR SUITE 300
HILLSBORO OR
97124-5860
US

IV. Provider business mailing address

267 N 10TH AVE APT 31
CORNELIUS OR
97113-9166
US

V. Phone/Fax

Practice location:
  • Phone: 503-531-1700
  • Fax:
Mailing address:
  • Phone: 503-531-1700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: