=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023769643
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. JUSTINE E WALSTON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2022
-----------------------------------------------------
Last Update Date | 01/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10209 SE SUNNYSIDE RD
-----------------------------------------------------
City | CLACKAMAS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97015-9782
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-813-2000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1352 NW ST
-----------------------------------------------------
City | ESTACADA
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-756-6999
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 126800000X
-----------------------------------------------------
Taxonomy Name | Dental Assistant
-----------------------------------------------------
License Number | 122616
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------