Provider Demographics
NPI:1528545514
Name:KAWASAKI-JONES, KELLIE MICHIKO
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:MICHIKO
Last Name:KAWASAKI-JONES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:
Other - Last Name:KAWASAKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:6950 NE CAMPUS WAY
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-5611
Mailing Address - Country:US
Mailing Address - Phone:855-433-6825
Mailing Address - Fax:
Practice Address - Street 1:62968 OB RILEY ROAD
Practice Address - Street 2:SUITE 12
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701
Practice Address - Country:US
Practice Address - Phone:855-433-6825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-23
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD10873122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist