Provider Demographics
NPI:1851880199
Name:KAISER FOUNDATION HEALTH PLAN NORTHWEST
Entity Type:Organization
Organization Name:KAISER FOUNDATION HEALTH PLAN NORTHWEST
Other - Org Name:KAISER PERMANENTE 3 TO PHD DENTAL
Other - Org Type:Other Name
Authorized Official - Title/Position:DENTAL BUSINESS LEADER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:MARKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-813-4660
Mailing Address - Street 1:500 NE MULTNOMAH ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2023
Mailing Address - Country:US
Mailing Address - Phone:503-813-4939
Mailing Address - Fax:
Practice Address - Street 1:2930 NE DEKUM ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-6613
Practice Address - Country:US
Practice Address - Phone:800-813-2000
Practice Address - Fax:503-286-6879
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KAISER FOUNDATION HEALTH PLAN NORTHWEST
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-05-02
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500675725Medicaid