Provider Demographics
NPI:1255038162
Name:LEE, LAURA RENE (RDH)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:RENE
Last Name:LEE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:RENE
Other - Last Name:BETHURUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 462
Mailing Address - Street 2:
Mailing Address - City:CRESWELL
Mailing Address - State:OR
Mailing Address - Zip Code:97426-0462
Mailing Address - Country:US
Mailing Address - Phone:541-844-9235
Mailing Address - Fax:
Practice Address - Street 1:2510 GAME FARM RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-7513
Practice Address - Country:US
Practice Address - Phone:541-844-9235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-10
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH3397124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty