Provider Demographics
NPI:1609369594
Name:MULNOMAH COUNTY
Entity Type:Organization
Organization Name:MULNOMAH COUNTY
Other - Org Name:MULTNOMAH COUNTY SCHOOL ORAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-988-7462
Mailing Address - Street 1:421 SW OAK ST STE 210
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97204-1842
Mailing Address - Country:US
Mailing Address - Phone:503-988-7468
Mailing Address - Fax:503-988-3015
Practice Address - Street 1:3505 SE 182ND AVE
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-5028
Practice Address - Country:US
Practice Address - Phone:503-988-5488
Practice Address - Fax:503-988-5484
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MULNOMAH COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-06-14
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR022959Medicaid