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General NPI Number Information
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NPI Number | 1457763195
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Entity Type | Organization
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Legal Business Name | WILLAMETTE DENTAL GROUP
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Dates
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Enumeration Date | 05/29/2014
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Last Update Date | 05/29/2014
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Provider Practice Location Address
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Address Line | 4925 SW GRIFFITH DR
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City | BEAVERTON
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State | OR
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Zip | 97005-2923
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Country | US
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Telephone | 503-444-1822
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Fax |
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Provider Business Mailing Address
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Address Line | 4925 SW GRIFFITH DR
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City | BEAVERTON
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State | OR
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Zip | 97005-2923
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Country | US
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Telephone | 503-444-1822
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Fax |
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Authorized Official
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Title or Position | DENTAL HYGIENIST
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Name | LINDSEY KATHLEEN REEVES
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Credential |
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Telephone | 503-444-1822
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number | H6635
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License Number State | OR
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