Provider Demographics
NPI:1386935211
Name:CHITWOOD, KATHLEEN MARR (RDH,LAP)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARR
Last Name:CHITWOOD
Suffix:
Gender:F
Credentials:RDH,LAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12552 CENTERWOOD RD SE
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:OR
Mailing Address - Zip Code:97352-9283
Mailing Address - Country:US
Mailing Address - Phone:503-363-9544
Mailing Address - Fax:
Practice Address - Street 1:12552 CENTERWOOD RD SE
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:OR
Practice Address - Zip Code:97352-9283
Practice Address - Country:US
Practice Address - Phone:503-990-7099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-26
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH0478124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist