Healthcare Provider Details

I. General information

NPI: 1356708523
Provider Name (Legal Business Name): MRS. STACY WOOD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2016
Last Update Date: 01/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 MCLOUGHLIN BLVD SUITE 68
OREGON CITY OR
97045-1067
US

IV. Provider business mailing address

916 NW 1ST AVE
CANBY OR
97013-3455
US

V. Phone/Fax

Practice location:
  • Phone: 503-387-8000
  • Fax:
Mailing address:
  • Phone: 503-729-2661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: