Healthcare Provider Details

I. General information

NPI: 1043224678
Provider Name (Legal Business Name): KAISER PERMANENTE DENTAL CARE PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 05/24/2021
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12711 SE MILL PLAIN BLVD
VANCOUVER WA
98684-6053
US

IV. Provider business mailing address

510 W 34TH ST
VANCOUVER WA
98660-1811
US

V. Phone/Fax

Practice location:
  • Phone: 360-896-4484
  • Fax:
Mailing address:
  • Phone: 360-695-7208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH00004025
License Number StateWA

VIII. Authorized Official

Name: DR. JODEEN CALLAGHAN
Title or Position: PROFESSIONAL DIRECTOR, CASCADE PARK
Credential: DMD
Phone: 360-896-4484