Provider Demographics
NPI:1003828203
Name:WADE, MARY MICHELLE (RDH)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MICHELLE
Last Name:WADE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:MICHELLE
Other - Last Name:FELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3062 SEMINOLE RD NE
Mailing Address - Street 2:
Mailing Address - City:SILVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97381-9469
Mailing Address - Country:US
Mailing Address - Phone:503-873-5982
Mailing Address - Fax:
Practice Address - Street 1:2300 LANCASTER DR NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1223
Practice Address - Country:US
Practice Address - Phone:503-370-4843
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH2787124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist