Healthcare Provider Details

I. General information

NPI: 1225141898
Provider Name (Legal Business Name): LORI L VIRELL EFDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2006
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

19183 SE YAMHILL ST CONDO #11
PORTLAND OR
97233-3960
US

V. Phone/Fax

Practice location:
  • Phone: 503-257-5959
  • Fax: 503-408-1472
Mailing address:
  • Phone: 503-665-0999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License NumberA2312
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: