Provider Demographics
NPI:1962716340
Name:MULLENS, KATIE M (RDH)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:M
Last Name:MULLENS
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 1:1735 NE AINSWORTH ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-4966
Mailing Address - Country:US
Mailing Address - Phone:309-737-0818
Mailing Address - Fax:
Practice Address - Street 1:426 SW STARK ST
Practice Address - Street 2:9TH FLOOR
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97204-2347
Practice Address - Country:US
Practice Address - Phone:503-988-3663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-28
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH5961124Q00000X
WI10814-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist