Healthcare Provider Details

I. General information

NPI: 1881065076
Provider Name (Legal Business Name): SPOKANE ORAL SURGERY ASC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2015
Last Update Date: 10/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12109 E BROADWAY AVE STE 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: 509-242-3336
  • Fax: 866-554-1392
Mailing address:
  • Phone: 509-242-3336
  • Fax: 866-554-1392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number StateWA

VIII. Authorized Official

Name: DR. MARK CHRISTOPHER PAXTON
Title or Position: OWNER
Credential: DDS
Phone: 509-242-3336