MEDICARE: MRS. LAURIE LEE KELLY RDH

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	H2626	OR

General Provider Information

NPI Number	:	1467517664
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LAURIE LEE KELLY RDH

Provider Business Mailing Address
First Line	:	4550 DOGWOOD DR
Second Line	:
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97035-8410
Country	:	US
Telephone Number	:	503-310-9485
Fax Number	:	503-620-1635

Provider Business Practice Location Address
First Line	:	4550 DOGWOOD DR
Second Line	:
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97035-8410
Country	:	US
Telephone Number	:	503-310-9485
Fax Number	:	503-620-1635

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

Provider Enumeration Date	:	12/27/2006
Last Update Date	:	07/08/2007

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