Provider Demographics
NPI:1558653436
Name:NELSON, SALLY LYNN (RDH)
Entity Type:Individual
Prefix:MRS
First Name:SALLY
Middle Name:LYNN
Last Name:NELSON
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 1:17704 JEAN WAY
Mailing Address - Street 2:SUITE 105
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-5497
Mailing Address - Country:US
Mailing Address - Phone:971-236-9356
Mailing Address - Fax:
Practice Address - Street 1:17704 JEAN WAY
Practice Address - Street 2:SUITE 105
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-5497
Practice Address - Country:US
Practice Address - Phone:971-236-9356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-10
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH2216124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORH2216OtherR.D.H