Provider Demographics
NPI:1427406594
Name:COLEMAN, KASSANDRA
Entity Type:Individual
Prefix:
First Name:KASSANDRA
Middle Name:
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 MARKET ST NE
Mailing Address - Street 2:#228
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-1882
Mailing Address - Country:US
Mailing Address - Phone:503-585-5205
Mailing Address - Fax:
Practice Address - Street 1:3000 MARKET ST NE
Practice Address - Street 2:#228
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-1882
Practice Address - Country:US
Practice Address - Phone:503-585-5205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-31
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH7181124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist