Healthcare Provider Details

I. General information

NPI: 1861918005
Provider Name (Legal Business Name): KAISER PERMANENTE DENTAL CARE PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2017
Last Update Date: 06/01/2021
Certification Date: 06/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2930 NE DEKUM ST
PORTLAND OR
97211-6613
US

IV. Provider business mailing address

500 NE MULTNOMAH ST
PORTLAND OR
97232-2023
US

V. Phone/Fax

Practice location:
  • Phone: 800-813-2000
  • Fax: 503-286-6879
Mailing address:
  • Phone: 800-813-2000
  • Fax: 503-286-6879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State

VIII. Authorized Official

Name: MRS. AMY MARKO
Title or Position: DENTAL BUSINESS LEADER
Credential:
Phone: 503-813-4660