=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083553630
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GLACIER ORAL & MAXILLOFACIAL SURGERY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2026
-----------------------------------------------------
Last Update Date | 03/27/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 515 HWY 9 STE 102
-----------------------------------------------------
City | LAKE STEVENS
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98258-8523
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-439-7446
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7718 19TH PL SE
-----------------------------------------------------
City | LAKE STEVENS
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98258-3212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-293-1375
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER DENTIST
-----------------------------------------------------
Name | DR. BENJAMIN NOBLITT
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 425-293-1372
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QS0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------