NPI 1194143065

Willamette Dental

Organisation Health Maintenance Organization Beaverton, OR

Practice location

Address: 4925 SW Griffith Dr, Beaverton, OR 97005-2923
Phone: (855) 433-6825
Mailing address: 1333 SE 194th Pl, Camas, WA 98607-8664

Authorised official

Name: Manimone Phanthamath
Title: Dental Hygienist
Phone: (503) 715-7876

Registered specialties

Health Maintenance Organization Primary

Managed Care Organizations Taxonomy 302R00000X Licence H5456 (OR)

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Registry record

NPI: 1194143065
Entity type: Organization
NPI issued: 28 Mar 2014
Record last updated: 28 Mar 2014

Reproduced from NPPES, the federal provider registry. The date above is when the provider last updated their own entry, not when we fetched it - a record can be years old and still current in the registry.