MEDICARE: SPOKANE OMS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)		WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1497789820
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPOKANE OMS

Provider Business Mailing Address
First Line	:	12109 E BROADWAY AVE STE C
Second Line	:
City	:	SPOKANE VALLEY
State	:	WA
Zip	:	99206-6133
Country	:	US
Telephone Number	:	509-926-7106
Fax Number	:	509-926-2833

Provider Business Practice Location Address
First Line	:	12109 E BROADWAY AVENUE SUITE C
Second Line	:
City	:	SPOKANE VALLEY
State	:	WA
Zip	:	99206-6133
Country	:	US
Telephone Number	:	509-926-7106
Fax Number	:	509-926-2833

Authorized Official
Title or Position	:	COO
Name	:	MRS. MARLA A TELIN
Credential	:
Telephone Number	:	509-926-7106

Provider Enumeration Date	:	07/10/2006
Last Update Date	:	07/21/2022

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Directions to “SPOKANE OMS ” Practice Location

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