Provider Demographics
NPI:1477707313
Name:MAHLBERG, SHANNAN R (RDH)
Entity Type:Individual
Prefix:
First Name:SHANNAN
Middle Name:R
Last Name:MAHLBERG
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:SHANNAN
Other - Middle Name:R
Other - Last Name:NEMEC
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RDH
Mailing Address - Street 1:3390 QUAIL RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-3692
Mailing Address - Country:US
Mailing Address - Phone:503-505-1335
Mailing Address - Fax:503-723-0621
Practice Address - Street 1:3390 QUAIL RIDGE CT
Practice Address - Street 2:
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97068-3692
Practice Address - Country:US
Practice Address - Phone:503-505-1335
Practice Address - Fax:503-723-0621
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-05
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH3707124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORH3707OtherODA