Provider Demographics
NPI:1699127993
Name:DIBALA, JEANETTE (SA-C)
Entity type:Individual
Prefix:
First Name:JEANETTE
Middle Name:
Last Name:DIBALA
Suffix:
Gender:F
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12353 SILVERTON RD NE
Mailing Address - Street 2:
Mailing Address - City:SILVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97381-9363
Mailing Address - Country:US
Mailing Address - Phone:503-428-4983
Mailing Address - Fax:503-873-1707
Practice Address - Street 1:342 FAIRVIEW ST
Practice Address - Street 2:
Practice Address - City:SILVERTON
Practice Address - State:OR
Practice Address - Zip Code:97381-1917
Practice Address - Country:US
Practice Address - Phone:503-873-1713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-11
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16-379246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant