Healthcare Provider Details

I. General information

NPI: 1023389079
Provider Name (Legal Business Name): DIANA ANATOLIEVNA IPACS SZABO RDH, BS, LAP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2012
Last Update Date: 01/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5770 MACLEAY RD SE
SALEM OR
97317-9238
US

IV. Provider business mailing address

5770 MACLEAY RD SE
SALEM OR
97317-9238
US

V. Phone/Fax

Practice location:
  • Phone: 503-956-8811
  • Fax:
Mailing address:
  • Phone: 503-956-8811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH5709
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: