Healthcare Provider Details

I. General information

NPI: 1538273537
Provider Name (Legal Business Name): KATHLEEN ANN WINTER EFDA DENTAL ASSISTAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1314 NE GRAND AVE
PORTLAND OR
97232-1127
US

IV. Provider business mailing address

1314 NE GRAND AVE
PORTLAND OR
97232-1127
US

V. Phone/Fax

Practice location:
  • Phone: 503-280-2877
  • Fax: 503-331-3095
Mailing address:
  • Phone: 503-280-2877
  • Fax: 503-331-3095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number0668
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: