Provider Demographics
NPI:1942581681
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:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:WERNER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:253-579-0000
Mailing Address - Street 1:1100 STATION DR STE 181
Mailing Address - Street 2:
Mailing Address - City:DUPONT
Mailing Address - State:WA
Mailing Address - Zip Code:98327-9777
Mailing Address - Country:US
Mailing Address - Phone:253-579-0000
Mailing Address - Fax:253-579-0010
Practice Address - Street 1:1100 STATION DR STE 181
Practice Address - Street 2:
Practice Address - City:DUPONT
Practice Address - State:WA
Practice Address - Zip Code:98327-9777
Practice Address - Country:US
Practice Address - Phone:253-579-0000
Practice Address - Fax:253-579-0010
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DUPONT ORAL SURGERY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-09-08
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA80391223S0112X
WA71711223S0112X
WA99131223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1223S0112XMedicaid