Organization
PROVIDENCE HEALTH & SERVICES - OREGON
Active
Other names
Providence Oral Head and Neck Clinic, PROVIDENCE MEDICAL GROUP
Organization subpart
No
Provider details
NPI number
Authorized official
DONALD WAYNE ANDERSON JR. (ASSISTANT SECRETARY ENROLLMENT)
(425) 358-9786
Entity
Organization
Contact information
Practice address
4805 NE GLISAN ST STE 11N, PORTLAND, OR 97213-2933
(503) 215-3053
(503) 215-3037
Mailing address
PO BOX 31001 - 4180, PASADENA, CA 91110-4180
Taxonomy
Speciality
Code
Description
License number
State
204E00000X
Oral & Maxillofacial Surgery (D.M.D.)
Primary
—
—
261Q00000X
Clinic/Center
—
—
Other
Enumeration date
10/22/2012
Last updated
03/23/2026
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