Healthcare Provider Details

I. General information

NPI: 1609369594
Provider Name (Legal Business Name): MULNOMAH COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2018
Last Update Date: 05/18/2024
Certification Date: 05/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3505 SE 182ND AVE
GRESHAM OR
97030-5028
US

IV. Provider business mailing address

421 SW OAK ST STE 210
PORTLAND OR
97204-1842
US

V. Phone/Fax

Practice location:
  • Phone: 503-988-5488
  • Fax: 503-988-5484
Mailing address:
  • Phone: 503-988-7468
  • Fax: 503-988-3015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier022959
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: DERRICK MOTEN
Title or Position: INTERIM BUSINESS SERVICES DIRECTOR
Credential:
Phone: 503-988-2966