Healthcare Provider Details

I. General information

NPI: 1043644685
Provider Name (Legal Business Name): KATHINA JUSTICE R.D.H., A.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2013
Last Update Date: 08/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1896 NE LUCY BELLE ST
MCMINNVILLE OR
97128-9259
US

IV. Provider business mailing address

1896 NE LUCY BELLE ST
MCMINNVILLE OR
97128-9259
US

V. Phone/Fax

Practice location:
  • Phone: 503-435-9542
  • Fax:
Mailing address:
  • Phone: 503-435-9542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH6511
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: