Provider Demographics
NPI:1346697075
Name:CHANDLER, KATHLEEN MARIE
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:CHANDLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:MARIE
Other - Last Name:LOE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:585 WORMWOOD ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97306-1762
Mailing Address - Country:US
Mailing Address - Phone:503-798-2198
Mailing Address - Fax:
Practice Address - Street 1:1595 COMMERCIAL ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4309
Practice Address - Country:US
Practice Address - Phone:503-363-2536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-23
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH6702124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist