Provider Demographics
NPI:1467517664
Name:KELLY, LAURIE LEE (RDH)
Entity Type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:LEE
Last Name:KELLY
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 1:4550 DOGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-8410
Mailing Address - Country:US
Mailing Address - Phone:503-310-9485
Mailing Address - Fax:503-620-1635
Practice Address - Street 1:4550 DOGWOOD DR
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-8410
Practice Address - Country:US
Practice Address - Phone:503-310-9485
Practice Address - Fax:503-620-1635
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH2626124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist