Provider Demographics
NPI:1922689207
Name:PETERSON, LESLIE LUCINDA (RDH, OMT)
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:LUCINDA
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RDH, OMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6590 SW FALLBROOK PL STE 2
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97008-5465
Mailing Address - Country:US
Mailing Address - Phone:503-922-6636
Mailing Address - Fax:
Practice Address - Street 1:6590 SW FALLBROOK PL STE 2
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97008-5465
Practice Address - Country:US
Practice Address - Phone:503-922-6636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-18
Last Update Date:2021-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No124Q00000XDental ProvidersDental Hygienist