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2730 S Moody Ave Portland OR 97201-5042 | |
| (503) 494-8867 | |
| (503) 494-2365 |
| Full Name | |
|---|---|
| Speciality | Dentist |
| Location | 2730 S Moody Ave, Portland, Oregon |
| Authorized Official Name and Position | Phillip T Marucha (DEAN) |
| Authorized Official Contact | 5034948801 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
2730 S Moody Ave Portland OR 97201-5042 Ph: (503) 494-8867 | 2730 S Moody Ave Portland OR 97201-5042 Ph: (503) 494-8867 |
| NPI Number | 1063596690 |
|---|---|
| Provider Enumeration Date | 10/24/2006 |
| Last Update Date | 03/21/2023 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1063596690 | NPI | - | NPPES |
| 149518 | Medicaid | OR | |
| 5729603 | Medicaid | WA |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 122300000X | Dentist | (* (Not Available)) | Primary |
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