Healthcare Provider Details

I. General information

NPI: 1396830238
Provider Name (Legal Business Name): SOUTH SOUND ORAL SURGERY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 W 1ST ST STE A
CENTRALIA WA
98531-3018
US

IV. Provider business mailing address

1220 W 1ST W STE A
CENTRALIA WA
98531
US

V. Phone/Fax

Practice location:
  • Phone: 360-736-0715
  • Fax: 360-330-5091
Mailing address:
  • Phone: 360-736-0715
  • Fax: 360-330-5091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: MRS. LAURA JEAN CASWELL
Title or Position: OFFICE MANAGER
Credential:
Phone: 360-736-0715