Basic Information
| Provider Information | |||||||||
| NPI: | 1194143065 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WILLAMETTE DENTAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1333 SE 194TH PL | ||||||||
| Address2: | |||||||||
| City: | CAMAS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986078664 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4925 SW GRIFFITH DR | ||||||||
| Address2: | |||||||||
| City: | BEAVERTON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970052923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8554336825 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2014 | ||||||||
| LastUpdateDate: | 03/28/2014 | ||||||||
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| AuthorizedOfficialLastName: | PHANTHAMATH | ||||||||
| AuthorizedOfficialFirstName: | MANIMONE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DENTAL HYGIENIST | ||||||||
| AuthorizedOfficialTelephone: | 5037157876 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RDH | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302R00000X | H5456 | OR | Y | Managed Care Organizations | Health Maintenance Organization |
No ID Information.