Provider Demographics
NPI:1043437148
Name:VAUGHN, MICHELLE ANN (RDH)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANN
Last Name:VAUGHN
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 1:12345 SE BYBEE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-5013
Mailing Address - Country:US
Mailing Address - Phone:971-344-3732
Mailing Address - Fax:
Practice Address - Street 1:10209 SE SUNNYSIDE RD.
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015
Practice Address - Country:US
Practice Address - Phone:503-353-3900
Practice Address - Fax:503-353-3903
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR113959126800000X
ORH6304124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
No126800000XDental ProvidersDental Assistant