Individual
MARISSA GARDNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
1245 FULTON AVE, COOS BAY, OR 97420-2895
(541) 888-6433
Mailing address
1245 FULTON AVE, COOS BAY, OR 97420-2895
Taxonomy
Speciality
Code
Description
License number
State
125J00000X
Dental Therapist
DT0005
OR
247200000X
Other Technician
Primary
—
—
Other
Enumeration date
07/05/2018
Last updated
09/17/2024
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