Provider Demographics
NPI:1326598335
Name:ANSLEY, KELLY (RDH)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:ANSLEY
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 1:6420 SW MACADAM AVE
Mailing Address - Street 2:#300
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3507
Mailing Address - Country:US
Mailing Address - Phone:503-941-3077
Mailing Address - Fax:
Practice Address - Street 1:19029 BEAVERCREEK RD
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-9537
Practice Address - Country:US
Practice Address - Phone:503-941-3067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-13
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH6552124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist