Basic Information
Provider Information
NPI: 1003142902
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: VAN BUREN
FirstName: JOANNE
MiddleName: T
NamePrefix:  
NameSuffix:  
Credential: RDH
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1890 NE 162ND AVE
Address2:  
City: PORTLAND
State: OR
PostalCode: 972305642
CountryCode: US
TelephoneNumber: 5032579836
FaxNumber:  
Practice Location
Address1: 1890 NE 162ND AVE
Address2:  
City: PORTLAND
State: OR
PostalCode: 972305642
CountryCode: US
TelephoneNumber: 5032579836
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/27/2009
LastUpdateDate: 10/27/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
124Q00000XH2618ORY Dental ProvidersDental Hygienist 

No ID Information.


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