| Southeast Dental Clinic | |
|
3653 Se 34th Ave Portland OR 97202-3034 | |
| (503) 988-4410 | |
| Not Available |
| Full Name | Southeast Dental Clinic |
|---|---|
| Speciality | Clinic/center - Federally Qualified Health Center (fqhc) |
| Location | 3653 Se 34th Ave, Portland, Oregon |
| Authorized Official Name and Position | Cammy Gaddis (FINANCE SPECIALIST) |
| Authorized Official Contact | 5039887468 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Southeast Dental Clinic 619 Nw 6th Ave Ste 210 Portland OR 97209-3964 Ph: (503) 988-7468 | Southeast Dental Clinic 3653 Se 34th Ave Portland OR 97202-3034 Ph: (503) 988-4410 |
| NPI Number | 1285136820 |
|---|---|
| Provider Enumeration Date | 02/28/2018 |
| Last Update Date | 03/16/2019 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1285136820 | 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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