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General NPI Number Information
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NPI Number | 1841084209
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Entity Type | Individual
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Provider Name | LEAH BOLLE-VAN LOO
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Gender | Female
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Dates
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Enumeration Date | 04/08/2025
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Last Update Date | 04/08/2025
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Provider Practice Location Address
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Address Line | 1885 WAITE ST
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City | NORTH BEND
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State | OR
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Zip | 97459-1210
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Country | US
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Telephone | 541-696-5006
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Fax | 541-756-6234
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Provider Business Mailing Address
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Address Line | 1890 WAITE ST STE 1
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City | NORTH BEND
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State | OR
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Zip | 97459-1229
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Country | US
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Telephone | 541-756-6232
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Fax | 541-756-6234
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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 | 126800000X
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Taxonomy Name | Dental Assistant
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License Number | 002377
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License Number State | OR
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