Basic Information
| Provider Information | |||||||||
| NPI: | 1073650552 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | INNES | ||||||||
| FirstName: | SNEHA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1334 NE HARVEST HEIGHTS LN | ||||||||
| Address2: | |||||||||
| City: | GRANTS PASS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975263647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078649904 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 25647 REDWOOD HWY | ||||||||
| Address2: | |||||||||
| City: | CAVE JUNCTION | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975239332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414714111 | ||||||||
| FaxNumber: | 5415923916 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2007 | ||||||||
| LastUpdateDate: | 10/11/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 54789 | CA | N | Dental Providers | Dentist | 122300000X | 11417672-9921 | UT | N | Dental Providers | Dentist | 122300000X | D11608 | OR | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 11417672-9921 | 01 | UT | DDS LICENSE | OTHER | D11608 | 01 | OR | DDS LICENSE | OTHER | 54789 | 01 | CA | DDS LICENSE | OTHER |