Provider Demographics
NPI:1689090110
Name:WENATCHEE VALLEY ORAL AND FACIAL SURGERY
Entity Type:Organization
Organization Name:WENATCHEE VALLEY ORAL AND FACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMIAH
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MD
Authorized Official - Phone:509-663-0060
Mailing Address - Street 1:620 N EMERSON AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-6619
Mailing Address - Country:US
Mailing Address - Phone:509-663-0068
Mailing Address - Fax:509-663-0060
Practice Address - Street 1:620 N EMERSON AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-6619
Practice Address - Country:US
Practice Address - Phone:509-663-0068
Practice Address - Fax:509-663-0060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-07
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60337452261QS0112X
WAMD60336798261QS0112X
ORD9077261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery