Healthcare Provider Details

I. General information

NPI: 1922418995
Provider Name (Legal Business Name): ANNA SERVO EFODA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2014
Last Update Date: 04/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 SE MCLOUGHLIN BLVD SUITE 68
OREGON CITY OR
97045
US

IV. Provider business mailing address

11675 SE 64TH AVE
MILWAUKIE OR
97222-2871
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number115718
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: