Provider Demographics
NPI:1861630808
Name:BLACKETER, SHEILA SUZANNE (RDH)
Entity Type:Individual
Prefix:MRS
First Name:SHEILA
Middle Name:SUZANNE
Last Name:BLACKETER
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 1:700 53RD AVE NW
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-3248
Mailing Address - Country:US
Mailing Address - Phone:503-871-5214
Mailing Address - Fax:
Practice Address - Street 1:700 53RD AVE NW
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97304-3248
Practice Address - Country:US
Practice Address - Phone:503-871-5214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-29
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH3855124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist