Provider Demographics
NPI:1326411919
Name:THERING, STACIE (RDH)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:THERING
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 1:4404 NE 83RD AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-4931
Mailing Address - Country:US
Mailing Address - Phone:503-475-8551
Mailing Address - Fax:
Practice Address - Street 1:4404 NE 83RD AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-4931
Practice Address - Country:US
Practice Address - Phone:503-475-8551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-05
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH6997124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist