Provider Demographics
NPI:1518164201
Name:DIEPENBROEK, ASTRID (RDH LIMITED ACCESS)
Entity Type:Individual
Prefix:
First Name:ASTRID
Middle Name:
Last Name:DIEPENBROEK
Suffix:
Gender:F
Credentials:RDH LIMITED ACCESS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1890 WAITE ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:NORTH BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97459-1229
Mailing Address - Country:US
Mailing Address - Phone:541-756-6232
Mailing Address - Fax:541-756-6234
Practice Address - Street 1:1890 WAITE ST
Practice Address - Street 2:SUITE 1
Practice Address - City:NORTH BEND
Practice Address - State:OR
Practice Address - Zip Code:97459-1229
Practice Address - Country:US
Practice Address - Phone:541-756-6232
Practice Address - Fax:541-756-6234
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH2672124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1619915113OtherWATERFALL CLINIC - GROUP NPI