Healthcare Provider Details

I. General information

NPI: 1023766565
Provider Name (Legal Business Name): JAWNT ORAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2022
Last Update Date: 03/14/2022
Certification Date: 03/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15823 WESTMINSTER WAY N
SHORELINE WA
98133-5928
US

IV. Provider business mailing address

15823 WESTMINSTER WAY N
SHORELINE WA
98133-5928
US

V. Phone/Fax

Practice location:
  • Phone: 206-848-5788
  • Fax: 206-734-3747
Mailing address:
  • Phone: 206-848-5788
  • Fax: 206-734-3747

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: MACKENZIE FOWLER
Title or Position: OFFICE COORDINATOR
Credential:
Phone: 360-391-7872