Healthcare Provider Details

I. General information

NPI: 1730638180
Provider Name (Legal Business Name): FACIAL ORAL AND DENTAL IMPLANT SURGERY ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2016
Last Update Date: 09/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1256 SE BISHOP BLVD SUITE I
PULLMAN WA
99163-5414
US

IV. Provider business mailing address

1256 SE BISHOP BLVD SUITE I
PULLMAN WA
99163-5414
US

V. Phone/Fax

Practice location:
  • Phone: 509-330-5020
  • Fax:
Mailing address:
  • Phone: 509-330-5020
  • Fax:

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: STEPHEN W HOLM
Title or Position: OWNER
Credential: DMD
Phone: 509-330-5020