Provider Demographics
NPI:1871843078
Name:BILLI ODEGAARD DENTAL CLINIC
Entity Type:Organization
Organization Name:BILLI ODEGAARD DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS SERVICES DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:LEAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-988-3663
Mailing Address - Street 1:619 NW 6TH AVE STE 500
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:503-988-3015
Practice Address - Street 1:33 NW BROADWAY
Practice Address - Street 2:STE 380
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-3580
Practice Address - Country:US
Practice Address - Phone:503-988-5770
Practice Address - Fax:503-988-5442
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MULTNOMAH COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-09-14
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QD0000X
OR261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR096511Medicaid
OR022959Medicaid