Provider Demographics
NPI:1043224678
Name:KAISER PERMANENTE DENTAL CARE PROGRAM
Entity Type:Organization
Organization Name:KAISER PERMANENTE DENTAL CARE PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROFESSIONAL DIRECTOR, CASCADE PARK
Authorized Official - Prefix:DR
Authorized Official - First Name:JODEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CALLAGHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:360-896-4484
Mailing Address - Street 1:510 W 34TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98660-1811
Mailing Address - Country:US
Mailing Address - Phone:360-695-7208
Mailing Address - Fax:
Practice Address - Street 1:12711 SE MILL PLAIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-6053
Practice Address - Country:US
Practice Address - Phone:360-896-4484
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH00004025124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty