Healthcare Provider Details

I. General information

NPI: 1083638563
Provider Name (Legal Business Name): MARLENE JOANNE CRANK RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10102 NE GLISAN ST
PORTLAND OR
97220-4456
US

IV. Provider business mailing address

1410 SW 31ST ST
GRESHAM OR
97080-9610
US

V. Phone/Fax

Practice location:
  • Phone: 503-275-5959
  • Fax:
Mailing address:
  • Phone: 503-666-6117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH1788
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: