Basic Information
| Provider Information | |||||||||
| NPI: | 1144575267 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WILLAMETTE VALLEY ORAL & MAXILLOFACIAL SURGEY, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 CHURCH ST SE STE 102 | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973013758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035811999 | ||||||||
| FaxNumber: | 5035811107 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 CHURCH ST SE STE 102 | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973013758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035811999 | ||||||||
| FaxNumber: | 5035811107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2012 | ||||||||
| LastUpdateDate: | 07/15/2012 | ||||||||
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| AuthorizedOfficialLastName: | EYRE | ||||||||
| AuthorizedOfficialFirstName: | HOLLY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5035811999 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | D6858 | OR | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
No ID Information.