Provider Demographics
NPI:1265880801
Name:LUTES, AUDREY LEIGH (RDH)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:LEIGH
Last Name:LUTES
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 1:31920 HISTORIC COLUMBIA RIVER HWY
Mailing Address - Street 2:
Mailing Address - City:TROUTDALE
Mailing Address - State:OR
Mailing Address - Zip Code:97060-9377
Mailing Address - Country:US
Mailing Address - Phone:503-515-2877
Mailing Address - Fax:
Practice Address - Street 1:3130 SE DIVISION STREET
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202
Practice Address - Country:US
Practice Address - Phone:503-515-2877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-24
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH6505124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist