| Northeast Dental Clinic | |
|
5329 Ne Mlk Jr Blvd Portland OR 97211-3237 | |
| (503) 988-3664 | |
| Not Available |
| Full Name | Northeast Dental Clinic |
|---|---|
| Speciality | Clinic/center - Federally Qualified Health Center (fqhc) |
| Location | 5329 Ne Mlk Jr Blvd, Portland, Oregon |
| Authorized Official Name and Position | Derrick Moten (INTERIM BUSINESS SERVICES DIRECTOR) |
| Authorized Official Contact | 5039882966 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Northeast Dental Clinic 619 Nw 6th Ave Portland OR 97209-3964 Ph: (503) 988-7468 | Northeast Dental Clinic 5329 Ne Mlk Jr Blvd Portland OR 97211-3237 Ph: (503) 988-3664 |
| NPI Number | 1336640960 |
|---|---|
| Provider Enumeration Date | 02/28/2018 |
| Last Update Date | 05/18/2024 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1336640960 | NPI | - | NPPES |
| 022959 | Medicaid | OR |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QD0000X | Clinic/center - Dental | (Oregon) | Secondary |
| 261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (Oregon) | Primary |
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