Provider Demographics
NPI:1689697005
Name:ODELL, JUANITA VALLES (DMD)
Entity Type:Individual
Prefix:DR
First Name:JUANITA
Middle Name:VALLES
Last Name:ODELL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5025 SE 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-4445
Mailing Address - Country:US
Mailing Address - Phone:503-238-4418
Mailing Address - Fax:
Practice Address - Street 1:5025 SE 28TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-4445
Practice Address - Country:US
Practice Address - Phone:503-238-4418
Practice Address - Fax:503-238-0360
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD84551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice