Healthcare Provider Details

I. General information

NPI: 1497789820
Provider Name (Legal Business Name): SPOKANE OMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12109 E BROADWAY AVENUE SUITE C
SPOKANE VALLEY WA
99206-6133
US

IV. Provider business mailing address

12109 E BROADWAY AVE STE C
SPOKANE VALLEY WA
99206-6133
US

V. Phone/Fax

Practice location:
  • Phone: 509-926-7106
  • Fax: 509-926-2833
Mailing address:
  • Phone: 509-926-7106
  • Fax: 509-926-2833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number StateWA

VIII. Authorized Official

Name: MRS. MARLA A TELIN
Title or Position: COO
Credential:
Phone: 509-926-7106