Provider Demographics
NPI:1073967832
Name:RUTLEDGE, CONNIE LYNNE
Entity Type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:LYNNE
Last Name:RUTLEDGE
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:CONNIE
Other - Middle Name:LYNNE
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:3750 CHEMAWA RD NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305
Mailing Address - Country:US
Mailing Address - Phone:503-304-7631
Mailing Address - Fax:503-304-7639
Practice Address - Street 1:3750 CHEMAWA RD NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305
Practice Address - Country:US
Practice Address - Phone:503-304-7631
Practice Address - Fax:503-304-7639
Is Sole Proprietor?:No
Enumeration Date:2016-04-19
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1540124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist