Provider Demographics
NPI:1831293422
Name:NELSON, SANDRA CHARLENE (RDH)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:CHARLENE
Last Name:NELSON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2829
Mailing Address - Street 2:13731 SE 127TH AVE
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015
Mailing Address - Country:US
Mailing Address - Phone:503-427-0846
Mailing Address - Fax:503-631-7924
Practice Address - Street 1:13731 SE 127TH AVE
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015
Practice Address - Country:US
Practice Address - Phone:503-427-0846
Practice Address - Fax:503-631-7924
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR140342124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist