Provider Demographics
NPI:1881065076
Name:SPOKANE ORAL SURGERY ASC
Entity type:Organization
Organization Name:SPOKANE ORAL SURGERY ASC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:PAXTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:509-242-3336
Mailing Address - Street 1:12109 E BROADWAY AVE STE C
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99206-6133
Mailing Address - Country:US
Mailing Address - Phone:509-242-3336
Mailing Address - Fax:866-554-1392
Practice Address - Street 1:12109 E BROADWAY AVE STE C
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99206-6133
Practice Address - Country:US
Practice Address - Phone:509-242-3336
Practice Address - Fax:866-554-1392
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPOKANE ORAL SURGERY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-10-13
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8940493Medicare UPIN