Provider Demographics
NPI:1447596366
Name:AXTELL, AIMEE RENEE (RDH)
Entity Type:Individual
Prefix:
First Name:AIMEE
Middle Name:RENEE
Last Name:AXTELL
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 1:142 SW HENDRICKS ST
Mailing Address - Street 2:
Mailing Address - City:SUBLIMITY
Mailing Address - State:OR
Mailing Address - Zip Code:97385-8902
Mailing Address - Country:US
Mailing Address - Phone:541-295-5557
Mailing Address - Fax:
Practice Address - Street 1:3490 LANCASTER DR NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1356
Practice Address - Country:US
Practice Address - Phone:503-540-9041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-20
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH6008124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist