Healthcare Provider Details

I. General information

NPI: 1811171275
Provider Name (Legal Business Name): EDMONDS ORAL SURGERY, P.S.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2007
Last Update Date: 12/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21701 76TH AVE W #202
EDMONDS WA
98026-7536
US

IV. Provider business mailing address

21701 76TH AVE W #202
EDMONDS WA
98026-7536
US

V. Phone/Fax

Practice location:
  • Phone: 425-744-1724
  • Fax: 425-744-1726
Mailing address:
  • Phone: 425-744-1724
  • Fax: 425-744-1726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number StateWA

VIII. Authorized Official

Name: DR. JOHN E HELDRIDGE
Title or Position: PARTNER/PRESIDENT
Credential: DDS
Phone: 425-744-1724