Provider Demographics
NPI:1780342212
Name:ALCANTARA RUIZ, JOSE ANTONIO (RDH)
Entity type:Individual
Prefix:
First Name:JOSE ANTONIO
Middle Name:
Last Name:ALCANTARA RUIZ
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6732 SE 80TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-7129
Mailing Address - Country:US
Mailing Address - Phone:503-847-6363
Mailing Address - Fax:
Practice Address - Street 1:610 HAWTHORNE AVE SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-5859
Practice Address - Country:US
Practice Address - Phone:503-585-5205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-01
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH8353124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist