Provider Demographics
NPI:1811171275
Name:EDMONDS ORAL SURGERY, P.S.
Entity type:Organization
Organization Name:EDMONDS ORAL SURGERY, P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:E
Authorized Official - Last Name:HELDRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:425-744-1724
Mailing Address - Street 1:21701 76TH AVE W
Mailing Address - Street 2:#202
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-7536
Mailing Address - Country:US
Mailing Address - Phone:425-744-1724
Mailing Address - Fax:425-744-1726
Practice Address - Street 1:21701 76TH AVE W
Practice Address - Street 2:#202
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-7536
Practice Address - Country:US
Practice Address - Phone:425-744-1724
Practice Address - Fax:425-744-1726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-20
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5350608Medicaid
WA5014691Medicaid
WA5014691Medicaid
T03005Medicare UPIN
WA5350608Medicaid