Healthcare Provider Details

I. General information

NPI: 1619242591
Provider Name (Legal Business Name): WILLAMETTE VALLEY ORAL & MAXILLOFACIAL SURGERY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2012
Last Update Date: 03/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3996 CORREDALE CT. S.
SALEM OR
97302
US

IV. Provider business mailing address

3996 CORREDALE CT S
SALEM OR
97302-9326
US

V. Phone/Fax

Practice location:
  • Phone: 503-581-1999
  • Fax: 503-581-1107
Mailing address:
  • Phone: 503-581-1999
  • Fax: 503-581-1107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: HOLLY JAYNE EYRE
Title or Position: OFFICE MANAGER
Credential:
Phone: 503-581-1999