Provider Demographics
NPI:1003912494
Name:POLLAN, GWENDOLYN EVE (EFDA)
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:EVE
Last Name:POLLAN
Suffix:
Gender:F
Credentials:EFDA
Other - Prefix:
Other - First Name:WENDY
Other - Middle Name:EVE
Other - Last Name:POLLAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:EFDA
Mailing Address - Street 1:13826 MEYERS RD APT 2147
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-7964
Mailing Address - Country:US
Mailing Address - Phone:503-238-4418
Mailing Address - Fax:503-238-0360
Practice Address - Street 1:5025 SE 28TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-4445
Practice Address - Country:US
Practice Address - Phone:503-238-4418
Practice Address - Fax:503-238-0360
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR112357126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant