Provider Demographics
NPI:1275876849
Name:SPOKANE ORAL AND MAXILLOFACIAL SURGERY ASC
Entity Type:Organization
Organization Name:SPOKANE ORAL AND MAXILLOFACIAL SURGERY ASC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:K
Authorized Official - Last Name:BANCROFT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-926-7106
Mailing Address - Street 1:12109 E BROADWAY AVE
Mailing Address - Street 2:BUILDING C
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 AVE
Practice Address - Street 2:BUILDING C
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?:Yes
Parent Organization LBN:SPOKANE OMS PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-04-02
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery