Provider Demographics
NPI:1609176262
Name:GRUBBS, HEIDI JO (LAP RDH)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:JO
Last Name:GRUBBS
Suffix:
Gender:F
Credentials:LAP RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19230 SW CONZELMANN RD
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:OR
Mailing Address - Zip Code:97140-8707
Mailing Address - Country:US
Mailing Address - Phone:503-997-3489
Mailing Address - Fax:
Practice Address - Street 1:19230 SW CONZELMANN RD
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:OR
Practice Address - Zip Code:97140-8707
Practice Address - Country:US
Practice Address - Phone:503-997-3489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-29
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH4842124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist