Provider Demographics
NPI:1417568668
Name:COUNTY OF TILLAMOOK
Entity Type:Organization
Organization Name:COUNTY OF TILLAMOOK
Other - Org Name:TILLAMOOK COUNTY HEALTH DEPARTMENT - DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARLENE
Authorized Official - Middle Name:L
Authorized Official - Last Name:PUTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:503-842-3922
Mailing Address - Street 1:PO BOX 489
Mailing Address - Street 2:
Mailing Address - City:TILLAMOOK
Mailing Address - State:OR
Mailing Address - Zip Code:97141-0489
Mailing Address - Country:US
Mailing Address - Phone:503-842-3900
Mailing Address - Fax:503-842-3903
Practice Address - Street 1:805 IVY AVE STE B
Practice Address - Street 2:
Practice Address - City:TILLAMOOK
Practice Address - State:OR
Practice Address - Zip Code:97141-3758
Practice Address - Country:US
Practice Address - Phone:503-842-3900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF TILLAMOOK
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-08-12
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR128756Medicaid