Healthcare Provider Details

I. General information

NPI: 1689090110
Provider Name (Legal Business Name): WENATCHEE VALLEY ORAL AND FACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2014
Last Update Date: 03/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 N EMERSON AVE SUITE 101
WENATCHEE WA
98801-6619
US

IV. Provider business mailing address

620 N EMERSON AVE SUITE 101
WENATCHEE WA
98801-6619
US

V. Phone/Fax

Practice location:
  • Phone: 509-663-0068
  • Fax: 509-663-0060
Mailing address:
  • Phone: 509-663-0068
  • Fax: 509-663-0060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License NumberMD60336798
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License NumberD9077
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License NumberDE60337452
License Number StateWA

VIII. Authorized Official

Name: DR. JEREMIAH JOHNSON
Title or Position: DOCTOR
Credential: DDS, MD
Phone: 509-663-0060