Provider Demographics
NPI:1790259679
Name:MOREHOUSE, TIA RAE (EPDH)
Entity Type:Individual
Prefix:
First Name:TIA
Middle Name:RAE
Last Name:MOREHOUSE
Suffix:
Gender:F
Credentials:EPDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1066 SWALE RIDGE LOOP
Mailing Address - Street 2:
Mailing Address - City:CRESWELL
Mailing Address - State:OR
Mailing Address - Zip Code:97426-4500
Mailing Address - Country:US
Mailing Address - Phone:541-761-4981
Mailing Address - Fax:
Practice Address - Street 1:1275 S RIVER RD
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:OR
Practice Address - Zip Code:97424-3906
Practice Address - Country:US
Practice Address - Phone:541-942-3383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-14
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH7523124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist