Provider Demographics
NPI:1386120681
Name:SHORT, KRISTEN (RDH)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:SHORT
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:PO BOX 6149
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97007-0149
Mailing Address - Country:US
Mailing Address - Phone:503-352-8642
Mailing Address - Fax:
Practice Address - Street 1:115 NE MAY LN
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-9272
Practice Address - Country:US
Practice Address - Phone:503-883-4764
Practice Address - Fax:503-883-4764
Is Sole Proprietor?:No
Enumeration Date:2018-07-19
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH7522124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist