Provider Demographics
NPI:1821445230
Name:MCDUFFIE, TESSIE
Entity Type:Individual
Prefix:
First Name:TESSIE
Middle Name:
Last Name:MCDUFFIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33634 MAZOUR DR
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OR
Mailing Address - Zip Code:97053-9776
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5440 SW WESTGATE DR
Practice Address - Street 2:#165
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97221-2420
Practice Address - Country:US
Practice Address - Phone:503-297-1471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-16
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH6841124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist