=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811769201
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURA ELENA LOAICIGA ULLOA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2023
-----------------------------------------------------
Last Update Date | 10/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1151 N ADAIR ST
-----------------------------------------------------
City | CORNELIUS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97113-8900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-359-5564
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 6149
-----------------------------------------------------
City | ALOHA
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97007-0149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | H8371
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------