Provider Demographics
NPI:1497789820
Name:SPOKANE OMS
Entity Type:Organization
Organization Name:SPOKANE OMS
Other - Org Name:SPOKANE ORAL & MAXILLOFACIAL SURGERY
Other - Org Type:Other Name
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARLA
Authorized Official - Middle Name:A
Authorized Official - Last Name:TELIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-926-7106
Mailing Address - Street 1:12109 E BROADWAY AVE STE C
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99206-6133
Mailing Address - Country:US
Mailing Address - Phone:509-926-7106
Mailing Address - Fax:509-926-2833
Practice Address - Street 1:12109 E BROADWAY AVENUE SUITE C
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99206-6133
Practice Address - Country:US
Practice Address - Phone:509-926-7106
Practice Address - Fax:509-926-2833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5036579Medicaid
WA5036579Medicaid