1083849913 NPI number — SALMON CREEK ORAL & MAXILLOFACIAL SURGERY,LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083849913 NPI number — SALMON CREEK ORAL & MAXILLOFACIAL SURGERY,LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SALMON CREEK ORAL & MAXILLOFACIAL SURGERY,LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083849913
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/19/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14411 NE 20TH AVE
Provider Second Line Business Mailing Address:
SUITE 111
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98686-6431
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-695-2400
Provider Business Mailing Address Fax Number:
360-906-1116

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14411 NE 20TH AVE
Provider Second Line Business Practice Location Address:
SUITE 111
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98686-6431
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-695-2400
Provider Business Practice Location Address Fax Number:
360-906-1116
Provider Enumeration Date:
05/21/2009

Additional Information

Authorized Official

Authorized Official Last Name:
WONG
Authorized Official First Name:
CRAIG
Authorized Official Middle Name:
W
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
360-695-2400

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  WA5774 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5049937 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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