Provider Demographics
NPI:1730307919
Name:LANDIS, JAN L (EFDA)
Entity Type:Individual
Prefix:MRS
First Name:JAN
Middle Name:L
Last Name:LANDIS
Suffix:
Gender:F
Credentials:EFDA
Other - Prefix:
Other - First Name:JAN
Other - Middle Name:L
Other - Last Name:KERN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:EFDA
Mailing Address - Street 1:8065 SW FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-6431
Mailing Address - Country:US
Mailing Address - Phone:503-240-4051
Mailing Address - Fax:503-286-6876
Practice Address - Street 1:7201 N INTERSTATE AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-5523
Practice Address - Country:US
Practice Address - Phone:503-240-4051
Practice Address - Fax:503-286-6876
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORA0038126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant