=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356878771
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACEY IRENE INLOES EFDA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2017
-----------------------------------------------------
Last Update Date | 05/16/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10209 SE SUNNYSIDE RD
-----------------------------------------------------
City | CLACKAMAS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97015-9782
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-353-3900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18848 ROSE RD
-----------------------------------------------------
City | OREGON CITY
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97045-8929
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-830-3518
-----------------------------------------------------
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 | 113490
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------