Provider Demographics
NPI:1174028369
Name:SHERRETT, REBECCA LYNN (EFDA)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:LYNN
Last Name:SHERRETT
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 1:16910 SE NAEGELI DR APT 2
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-1386
Mailing Address - Country:US
Mailing Address - Phone:503-750-5891
Mailing Address - Fax:
Practice Address - Street 1:2930 NE DEKUM ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-6613
Practice Address - Country:US
Practice Address - Phone:503-916-5908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-28
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant