Basic Information
| Provider Information | |||||||||
| NPI: | 1619242591 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WILLAMETTE VALLEY ORAL & MAXILLOFACIAL SURGERY, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3996 CORREDALE CT S | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973029326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035811999 | ||||||||
| FaxNumber: | 5035811107 | ||||||||
| Practice Location | |||||||||
| Address1: | 3996 CORREDALE CT. S. | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035811999 | ||||||||
| FaxNumber: | 5035811107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2012 | ||||||||
| LastUpdateDate: | 03/12/2012 | ||||||||
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| AuthorizedOfficialLastName: | EYRE | ||||||||
| AuthorizedOfficialFirstName: | HOLLY | ||||||||
| AuthorizedOfficialMiddleName: | JAYNE | ||||||||
| 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 | 204E00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery |
No ID Information.