Provider Demographics
NPI:1336640960
Name:MULTNOMAH COUNTY
Entity Type:Organization
Organization Name:MULTNOMAH COUNTY
Other - Org Name:NORTHEAST DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FINANCE SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:CAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:GADDIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-988-7468
Mailing Address - Street 1:619 NW 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-3964
Mailing Address - Country:US
Mailing Address - Phone:503-988-7468
Mailing Address - Fax:
Practice Address - Street 1:5329 NE MLK JR BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-3237
Practice Address - Country:US
Practice Address - Phone:503-988-3664
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MULTNOMAH COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-02-28
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR261QD0000X, 261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR022959Medicaid