Provider Demographics
NPI:1689080467
Name:PACIFIC NORTHWEST ORAL AND MAXILLOFACIAL SURGERY
Entity Type:Organization
Organization Name:PACIFIC NORTHWEST ORAL AND MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:425-277-1844
Mailing Address - Street 1:2345 SW 320TH ST
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98023-2568
Mailing Address - Country:US
Mailing Address - Phone:253-838-2123
Mailing Address - Fax:253-874-3624
Practice Address - Street 1:2345 SW 320TH ST
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98023-2568
Practice Address - Country:US
Practice Address - Phone:253-838-2123
Practice Address - Fax:253-874-3624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-01
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00006475261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery