MEDICARE: STEPHANIE LYNN BROUSE RDH, EPPDH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist	H3929	OR

General Provider Information

NPI Number	:	1396091575
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE LYNN BROUSE RDH, EPPDH

Provider Business Mailing Address
First Line	:	2157 BROADWAY AVE
Second Line	:
City	:	NORTH BEND
State	:	OR
Zip	:	97459-2329
Country	:	US
Telephone Number	:	503-880-6816
Fax Number	:

Provider Business Practice Location Address
First Line	:	2157 BROADWAY AVE
Second Line	:
City	:	NORTH BEND
State	:	OR
Zip	:	97459-2329
Country	:	US
Telephone Number	:	503-880-6816
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/25/2012
Last Update Date	:	08/07/2015

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