Healthcare Provider Details

I. General information

NPI: 1205938925
Provider Name (Legal Business Name): ELIZABETH JOSEPHA MCCLELLAN RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 LANCASTER DR NE
SALEM OR
97305-1223
US

IV. Provider business mailing address

1859 STATE ST
SALEM OR
97301-4344
US

V. Phone/Fax

Practice location:
  • Phone: 503-370-4313
  • Fax:
Mailing address:
  • Phone: 503-999-0496
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH3880
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: