Healthcare Provider Details

I. General information

NPI: 1114478039
Provider Name (Legal Business Name): MADELINE JEAN LARSON RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2016
Last Update Date: 10/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4205 NE 130TH AVE
VANCOUVER WA
98682-6855
US

IV. Provider business mailing address

4205 NE 130TH AVE
VANCOUVER WA
98682-6855
US

V. Phone/Fax

Practice location:
  • Phone: 360-448-8419
  • Fax:
Mailing address:
  • Phone: 360-448-8419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH7313
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: