Provider Demographics
NPI:1396091575
Name:BROUSE, STEPHANIE LYNN (RDH, EPPDH)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LYNN
Last Name:BROUSE
Suffix:
Gender:F
Credentials:RDH, EPPDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2157 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97459-2329
Mailing Address - Country:US
Mailing Address - Phone:503-880-6816
Mailing Address - Fax:
Practice Address - Street 1:2157 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:NORTH BEND
Practice Address - State:OR
Practice Address - Zip Code:97459-2329
Practice Address - Country:US
Practice Address - Phone:503-880-6816
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-25
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH3929124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist