Healthcare Provider Details

I. General information

NPI: 1841084209
Provider Name (Legal Business Name): LEAH BOLLE-VAN LOO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2025
Last Update Date: 04/08/2025
Certification Date: 04/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1885 WAITE ST
NORTH BEND OR
97459-1210
US

IV. Provider business mailing address

1890 WAITE ST STE 1
NORTH BEND OR
97459-1229
US

V. Phone/Fax

Practice location:
  • Phone: 541-696-5006
  • Fax: 541-756-6234
Mailing address:
  • Phone: 541-756-6232
  • Fax: 541-756-6234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number002377
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: