Provider Demographics
NPI:1902314487
Name:MAI, MADALENA THUY-LAN
Entity Type:Individual
Prefix:
First Name:MADALENA
Middle Name:THUY-LAN
Last Name:MAI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15406 NE ANDRA PL
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-4426
Mailing Address - Country:US
Mailing Address - Phone:503-408-8927
Mailing Address - Fax:
Practice Address - Street 1:360 NW BURNSIDE RD
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3852
Practice Address - Country:US
Practice Address - Phone:503-286-6868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-18
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH4181124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist