Provider Demographics
NPI:1821491770
Name:TICE, LAUREEN JANEL (RDH)
Entity Type:Individual
Prefix:MS
First Name:LAUREEN
Middle Name:JANEL
Last Name:TICE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:LAUREEN
Other - Middle Name:JANEL
Other - Last Name:GREENHALGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:P.O. BOX 749
Mailing Address - Street 2:
Mailing Address - City:CLATSKANIE
Mailing Address - State:OR
Mailing Address - Zip Code:97016
Mailing Address - Country:US
Mailing Address - Phone:503-728-2114
Mailing Address - Fax:503-728-3320
Practice Address - Street 1:400 SW BEL AIR DR.
Practice Address - Street 2:
Practice Address - City:CLATSKANIE
Practice Address - State:OR
Practice Address - Zip Code:97016
Practice Address - Country:US
Practice Address - Phone:503-728-2114
Practice Address - Fax:503-728-3322
Is Sole Proprietor?:No
Enumeration Date:2014-10-07
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH3408124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist