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General NPI Number Information
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NPI Number | 1538975248
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Entity Type | Individual
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Provider Name | JESSICA RAE SALAS-PRATT RDH
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Gender | Female
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Dates
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Enumeration Date | 12/06/2024
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Last Update Date | 12/06/2024
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Provider Practice Location Address
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Address Line | PO BOX 367
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City | LAPWAI
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State | ID
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Zip | 83540-0367
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Country | US
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Telephone | 208-843-2271
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Fax |
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Provider Business Mailing Address
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Address Line | 1904 BROADVIEW DR
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City | LEWISTON
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State | ID
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Zip | 83501-3964
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Country | US
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Telephone | 208-790-3471
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 124Q00000X
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Taxonomy Name | Dental Hygienist
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License Number | DH-3250EA
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License Number State | ID
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