Healthcare Provider Details

I. General information

NPI: 1275874091
Provider Name (Legal Business Name): KAISER PERMANENTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2013
Last Update Date: 03/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7105 SW HAMPTON ST
TIGARD OR
97223-8314
US

IV. Provider business mailing address

4302 SW VACUNA ST
PORTLAND OR
97219-7368
US

V. Phone/Fax

Practice location:
  • Phone: 503-684-9274
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number120925
License Number StateOR

VIII. Authorized Official

Name: MISS KOSAR SAAD MEMAN
Title or Position: ASSISTANT
Credential: EFDA EFODA
Phone: 503-688-4601