Organization
WILLAMETTE DENTAL
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MANIMONE PHANTHAMATH RDH (DENTAL HYGIENIST)
(503) 715-7876
Entity
Organization
Contact information
Practice address
4925 SW GRIFFITH DR, BEAVERTON, OR 97005-2923
(855) 433-6825
Mailing address
1333 SE 194TH PL, CAMAS, WA 98607-8664
Taxonomy
Speciality
Code
Description
License number
State
302R00000X
Health Maintenance Organization
Primary
H5456
OR
Other
Enumeration date
03/28/2014
Last updated
03/28/2014
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