Provider Demographics
NPI:1093848798
Name:POUL, PAMELA JO (EFDA)
Entity Type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:JO
Last Name:POUL
Suffix:
Gender:F
Credentials:EFDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1063 MOUNTAIN VIEW LANE
Mailing Address - Street 2:
Mailing Address - City:MOLALLA
Mailing Address - State:OR
Mailing Address - Zip Code:97038
Mailing Address - Country:US
Mailing Address - Phone:503-829-5075
Mailing Address - Fax:
Practice Address - Street 1:1063 MOUNTAIN VIEW LN
Practice Address - Street 2:
Practice Address - City:MOLALLA
Practice Address - State:OR
Practice Address - Zip Code:97038-7375
Practice Address - Country:US
Practice Address - Phone:503-829-5075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORA7688126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant