Provider Demographics
NPI:1306037908
Name:POTTER, JONALEE COZAKOS (RDH)
Entity Type:Individual
Prefix:
First Name:JONALEE
Middle Name:COZAKOS
Last Name:POTTER
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:PO BOX 6149
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97007-0149
Mailing Address - Country:US
Mailing Address - Phone:503-359-8501
Mailing Address - Fax:503-434-8597
Practice Address - Street 1:44 N 11TH AVE
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:OR
Practice Address - Zip Code:97113-9020
Practice Address - Country:US
Practice Address - Phone:503-359-8505
Practice Address - Fax:503-434-8597
Is Sole Proprietor?:No
Enumeration Date:2007-08-07
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT111930-9920124Q00000X
IDDH-1678124Q00000X
WAHL00007676124Q00000X
ORH1907124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist