Provider Demographics
NPI:1316535339
Name:BLUE LAKE ORAL AND MAXILLOFACIAL SURGERY, PC
Entity Type:Organization
Organization Name:BLUE LAKE ORAL AND MAXILLOFACIAL SURGERY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL AND MAXILLOFACIAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIE ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MD
Authorized Official - Phone:503-667-1431
Mailing Address - Street 1:1201 SE 223RD AVE STE 180
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-2577
Mailing Address - Country:US
Mailing Address - Phone:503-667-1431
Mailing Address - Fax:
Practice Address - Street 1:1201 SE 223RD AVE STE 180
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-2577
Practice Address - Country:US
Practice Address - Phone:503-667-1431
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-05
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery