Healthcare Provider Details

I. General information

NPI: 1184587073
Provider Name (Legal Business Name): SOMCHANH VONGSOURY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2025
Last Update Date: 12/08/2025
Certification Date: 12/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10626 SE 75TH AVE
MILWAUKIE OR
97222-2098
US

IV. Provider business mailing address

10626 SE 75TH AVE
MILWAUKIE OR
97222-2098
US

V. Phone/Fax

Practice location:
  • Phone: 503-822-0117
  • Fax:
Mailing address:
  • Phone: 503-822-0117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH4529
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: