Healthcare Provider Details

I. General information

NPI: 1689080467
Provider Name (Legal Business Name): PACIFIC NORTHWEST ORAL AND MAXILLOFACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2014
Last Update Date: 07/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2345 SW 320TH ST
FEDERAL WAY WA
98023-2568
US

IV. Provider business mailing address

2345 SW 320TH ST
FEDERAL WAY WA
98023-2568
US

V. Phone/Fax

Practice location:
  • Phone: 253-838-2123
  • Fax: 253-874-3624
Mailing address:
  • Phone: 253-838-2123
  • Fax: 253-874-3624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License NumberDE00006475
License Number StateWA

VIII. Authorized Official

Name: DR. CARL KENNETH JOHNSON
Title or Position: OWNER
Credential: DDS
Phone: 425-277-1844