1407944614 NPI number — SOUTH SOUND ORAL SURGERY PLLC

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 1407944614 NPI number — SOUTH SOUND ORAL SURGERY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH SOUND ORAL SURGERY PLLC
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:
1407944614
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3425 ENSIGN RD NE
Provider Second Line Business Mailing Address:
STE 310
Provider Business Mailing Address City Name:
OLYMPIA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98506
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-456-5678
Provider Business Mailing Address Fax Number:
360-456-1238

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3425 ENSIGN RD NE
Provider Second Line Business Practice Location Address:
SUITE 310
Provider Business Practice Location Address City Name:
OLYMPIA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-456-5678
Provider Business Practice Location Address Fax Number:
356-045-6123
Provider Enumeration Date:
10/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CASWELL
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
JEAN
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
360-736-0715

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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