Provider Demographics
NPI:1407125073
Name:VOLLSTEDT, JENNIFER CAMILLE (RDH)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:CAMILLE
Last Name:VOLLSTEDT
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:CAMILLE
Other - Last Name:BUSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2403 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:WASHOUGAL
Mailing Address - State:WA
Mailing Address - Zip Code:98671-8517
Mailing Address - Country:US
Mailing Address - Phone:503-816-7067
Mailing Address - Fax:
Practice Address - Street 1:2403 N 3RD ST
Practice Address - Street 2:
Practice Address - City:WASHOUGAL
Practice Address - State:WA
Practice Address - Zip Code:98671-8517
Practice Address - Country:US
Practice Address - Phone:503-816-7067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-27
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH60250684124Q00000X
ORH6179124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist