Basic Information
Provider Information | |||||||||
NPI: | 1447596366 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | AXTELL | ||||||||
FirstName: | AIMEE | ||||||||
MiddleName: | RENEE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RDH | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 142 SW HENDRICKS ST | ||||||||
Address2: |   | ||||||||
City: | SUBLIMITY | ||||||||
State: | OR | ||||||||
PostalCode: | 973858902 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5412955557 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3490 LANCASTER DR NE | ||||||||
Address2: |   | ||||||||
City: | SALEM | ||||||||
State: | OR | ||||||||
PostalCode: | 973051356 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5035409041 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/20/2012 | ||||||||
LastUpdateDate: | 12/26/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | H6008 | OR | Y |   | Dental Providers | Dental Hygienist |   |
No ID Information.