Provider Demographics
NPI:1407581242
Name:VANDIVER, KATIE LYNN (DENTAL HYGIENIST)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:LYNN
Last Name:VANDIVER
Suffix:
Gender:F
Credentials:DENTAL HYGIENIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37389 SCOTT DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OR
Mailing Address - Zip Code:97355-9596
Mailing Address - Country:US
Mailing Address - Phone:541-990-9625
Mailing Address - Fax:
Practice Address - Street 1:37389 SCOTT DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-9596
Practice Address - Country:US
Practice Address - Phone:541-990-9625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-17
Last Update Date:2022-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH4783124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist