Provider Demographics
NPI:1457637670
Name:SHAFFER, KELLI (RDH)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:SHAFFER
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 1:8239 SW 186TH AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97007-5533
Mailing Address - Country:US
Mailing Address - Phone:503-926-3974
Mailing Address - Fax:
Practice Address - Street 1:8239 SW 186TH AVE
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97007-5533
Practice Address - Country:US
Practice Address - Phone:503-926-3974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-01
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH5156124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist