Healthcare Provider Details

I. General information

NPI: 1750657615
Provider Name (Legal Business Name): LIZETTE NGUYEN RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2012
Last Update Date: 03/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 NE MAY LN
MCMINNVILLE OR
97128-9272
US

IV. Provider business mailing address

13910 SE GLADSTONE ST
PORTLAND OR
97236-3572
US

V. Phone/Fax

Practice location:
  • Phone: 503-883-4737
  • Fax:
Mailing address:
  • Phone: 503-754-0175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH5490
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: