Provider Demographics
NPI:1043369911
Name:MANN, LINDA SUE (RDH)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:SUE
Last Name:MANN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4605 CROISAN SCENIC WAY S
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-2244
Mailing Address - Country:US
Mailing Address - Phone:503-540-8841
Mailing Address - Fax:
Practice Address - Street 1:4605 CROISAN SCENIC WAY S
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-2244
Practice Address - Country:US
Practice Address - Phone:503-540-8841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH3321124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR274828Medicaid