Healthcare Provider Details

I. General information

NPI: 1083553630
Provider Name (Legal Business Name): GLACIER ORAL & MAXILLOFACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2026
Last Update Date: 03/27/2026
Certification Date: 03/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 HWY 9 STE 102
LAKE STEVENS WA
98258-8523
US

IV. Provider business mailing address

7718 19TH PL SE
LAKE STEVENS WA
98258-3212
US

V. Phone/Fax

Practice location:
  • Phone: 425-439-7446
  • Fax:
Mailing address:
  • Phone: 425-293-1375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. BENJAMIN NOBLITT
Title or Position: OWNER DENTIST
Credential: DMD
Phone: 425-293-1372