Provider Demographics
NPI:1427420470
Name:WIEDEMAN, SALLY D (RDH)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:D
Last Name:WIEDEMAN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:D
Other - Last Name:BEACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:1776 SW MADISON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1715
Mailing Address - Country:US
Mailing Address - Phone:503-224-1044
Mailing Address - Fax:503-621-2235
Practice Address - Street 1:12750 SE STARK ST BLDG E
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1539
Practice Address - Country:US
Practice Address - Phone:971-347-3009
Practice Address - Fax:971-256-3277
Is Sole Proprietor?:No
Enumeration Date:2015-10-28
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH6804124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500695952Medicaid