Provider Demographics
NPI:1144575267
Name:WILLAMETTE VALLEY ORAL & MAXILLOFACIAL SURGEY, INC.
Entity Type:Organization
Organization Name:WILLAMETTE VALLEY ORAL & MAXILLOFACIAL SURGEY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:J
Authorized Official - Last Name:EYRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-581-1999
Mailing Address - Street 1:250 CHURCH ST SE STE 102
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3758
Mailing Address - Country:US
Mailing Address - Phone:503-581-1999
Mailing Address - Fax:503-581-1107
Practice Address - Street 1:250 CHURCH ST SE STE 102
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3758
Practice Address - Country:US
Practice Address - Phone:503-581-1999
Practice Address - Fax:503-581-1107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-15
Last Update Date:2012-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD68581223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORG76082Medicare UPIN