Provider Demographics
NPI:1407944614
Name:SOUTH SOUND ORAL SURGERY PLLC
Entity Type:Organization
Organization Name:SOUTH SOUND ORAL SURGERY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:CASWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-736-0715
Mailing Address - Street 1:3425 ENSIGN RD NE
Mailing Address - Street 2:STE 310
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506
Mailing Address - Country:US
Mailing Address - Phone:360-456-5678
Mailing Address - Fax:360-456-1238
Practice Address - Street 1:3425 ENSIGN RD NE
Practice Address - Street 2:SUITE 310
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506
Practice Address - Country:US
Practice Address - Phone:360-456-5678
Practice Address - Fax:356-045-6123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty