Provider Demographics
NPI:1629445929
Name:NORTHWEST ORAL HEALTH OUTREACH LLC
Entity Type:Organization
Organization Name:NORTHWEST ORAL HEALTH OUTREACH LLC
Other - Org Name:NORTHWEST ORAL HEALTH OUTREACH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENDEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MPH
Authorized Official - Phone:509-607-1872
Mailing Address - Street 1:2353 LOWER GREEN CANYON RD
Mailing Address - Street 2:
Mailing Address - City:ELLENSBURG
Mailing Address - State:WA
Mailing Address - Zip Code:98926-8514
Mailing Address - Country:US
Mailing Address - Phone:509-607-1872
Mailing Address - Fax:
Practice Address - Street 1:2353 LOWER GREEN CANYON RD
Practice Address - Street 2:
Practice Address - City:ELLENSBURG
Practice Address - State:WA
Practice Address - Zip Code:98926-8514
Practice Address - Country:US
Practice Address - Phone:509-607-1872
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-21
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA603513887261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0255549OtherLABOR & INDUSTRIES
WA5060215Medicaid
WAAB38059Medicare Oscar/Certification