Provider Demographics
NPI:1194143065
Name:WILLAMETTE DENTAL
Entity type:Organization
Organization Name:WILLAMETTE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTAL HYGIENIST
Authorized Official - Prefix:
Authorized Official - First Name:MANIMONE
Authorized Official - Middle Name:
Authorized Official - Last Name:PHANTHAMATH
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:503-715-7876
Mailing Address - Street 1:1333 SE 194TH PL
Mailing Address - Street 2:
Mailing Address - City:CAMAS
Mailing Address - State:WA
Mailing Address - Zip Code:98607-8664
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4925 SW GRIFFITH DR
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-2923
Practice Address - Country:US
Practice Address - Phone:855-433-6825
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-28
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH5456302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization