Healthcare Provider Details

I. General information

NPI: 1861406944
Provider Name (Legal Business Name): KATHERINE I DETRICK 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

822 NE 181ST AVE
PORTLAND OR
97230-6708
US

IV. Provider business mailing address

38320 MILLER RD
SANDY OR
97055-6317
US

V. Phone/Fax

Practice location:
  • Phone: 503-661-5210
  • Fax: 503-669-3989
Mailing address:
  • Phone: 503-668-5495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH1844
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: