Provider Demographics
NPI:1811586761
Name:EVERGREEN ORAL SURGERY
Entity Type:Organization
Organization Name:EVERGREEN ORAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MINKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-243-6241
Mailing Address - Street 1:13894 SUNLADEN CT
Mailing Address - Street 2:
Mailing Address - City:PICKERINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43147-8216
Mailing Address - Country:US
Mailing Address - Phone:740-243-6241
Mailing Address - Fax:740-919-5871
Practice Address - Street 1:6050 TACOMA MALL BLVD STE 330
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-6811
Practice Address - Country:US
Practice Address - Phone:253-473-0651
Practice Address - Fax:253-444-0761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-14
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty