Provider Demographics
NPI:1770978157
Name:DUBOIS, LAVERNA LEE (RDH)
Entity type:Individual
Prefix:
First Name:LAVERNA
Middle Name:LEE
Last Name:DUBOIS
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 1:212 SI TOWN RD
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:WA
Mailing Address - Zip Code:98611-9345
Mailing Address - Country:US
Mailing Address - Phone:360-749-0040
Mailing Address - Fax:
Practice Address - Street 1:212 SI TOWN RD
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:WA
Practice Address - Zip Code:98611-9345
Practice Address - Country:US
Practice Address - Phone:360-749-0040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-01
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH60493383124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist