Provider Demographics
NPI:1982965976
Name:INLAND ORAL SURGERY P.S.
Entity Type:Organization
Organization Name:INLAND ORAL SURGERY P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:W. DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:509-953-4067
Mailing Address - Street 1:2204 E 29TH AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99203-3961
Mailing Address - Country:US
Mailing Address - Phone:509-321-1404
Mailing Address - Fax:509-321-0211
Practice Address - Street 1:2204 E 29TH AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99203-3961
Practice Address - Country:US
Practice Address - Phone:509-321-1404
Practice Address - Fax:509-321-0211
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INLAND ORAL SURGERY P.S.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-06-06
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000070061223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1609870070Medicaid