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General NPI Number Information
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NPI Number | 1669047973
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Entity Type | Organization
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Legal Business Name | THE AESTHETIC
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Dates
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Enumeration Date | 05/20/2021
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Last Update Date | 05/20/2021
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Provider Practice Location Address
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Address Line | 410 1ST ST
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City | LAKE OSWEGO
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State | OR
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Zip | 97034-3123
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Country | US
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Telephone | 971-313-1535
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Fax |
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Provider Business Mailing Address
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Address Line | 325 2ND ST APT 215
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City | LAKE OSWEGO
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State | OR
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Zip | 97034-3288
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Country | US
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Telephone | 971-313-1535
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Fax |
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Authorized Official
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Title or Position | OWNER/MANAGER
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Name | LISA STANDAGE
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Credential | RDH, EPDH
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Telephone | 971-313-1535
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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