Provider Demographics
NPI:1013066976
Name:CUSTER, JEAN RAE (RDH)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:RAE
Last Name:CUSTER
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 1:710 SW 6TH CT
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-6562
Mailing Address - Country:US
Mailing Address - Phone:503-293-2895
Mailing Address - Fax:
Practice Address - Street 1:10317 E BURNSIDE ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2733
Practice Address - Country:US
Practice Address - Phone:503-988-3905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1255124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist