Provider Demographics
NPI:1417320003
Name:TATE, MOLLIE CHRISTINA (RDH)
Entity Type:Individual
Prefix:
First Name:MOLLIE
Middle Name:CHRISTINA
Last Name:TATE
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 1:7654 SE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97267-2144
Mailing Address - Country:US
Mailing Address - Phone:503-358-3386
Mailing Address - Fax:
Practice Address - Street 1:13255 SE STARK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1548
Practice Address - Country:US
Practice Address - Phone:503-255-1901
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
ORH6992124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist