Provider Demographics
NPI:1083849913
Name:SALMON CREEK ORAL & MAXILLOFACIAL SURGERY,LLC
Entity Type:Organization
Organization Name:SALMON CREEK ORAL & MAXILLOFACIAL SURGERY,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:W
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:360-695-2400
Mailing Address - Street 1:14411 NE 20TH AVE
Mailing Address - Street 2:SUITE 111
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98686-6431
Mailing Address - Country:US
Mailing Address - Phone:360-695-2400
Mailing Address - Fax:360-906-1116
Practice Address - Street 1:14411 NE 20TH AVE
Practice Address - Street 2:SUITE 111
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-6431
Practice Address - Country:US
Practice Address - Phone:360-695-2400
Practice Address - Fax:360-906-1116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-21
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAWA57741223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5049937Medicaid