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General NPI Number Information
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NPI Number | 1689090110
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Entity Type | Organization
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Legal Business Name | WENATCHEE VALLEY ORAL AND FACIAL SURGERY
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Dates
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Enumeration Date | 03/07/2014
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Last Update Date | 03/07/2014
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Provider Practice Location Address
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Address Line | 620 N EMERSON AVE SUITE 101
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City | WENATCHEE
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State | WA
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Zip | 98801-6619
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Country | US
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Telephone | 509-663-0068
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Fax | 509-663-0060
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Provider Business Mailing Address
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Address Line | 620 N EMERSON AVE SUITE 101
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City | WENATCHEE
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State | WA
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Zip | 98801-6619
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Country | US
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Telephone | 509-663-0068
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Fax | 509-663-0060
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Authorized Official
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Title or Position | DOCTOR
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Name | DR. JEREMIAH JOHNSON
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Credential | DDS, MD
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Telephone | 509-663-0060
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QS0112X
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Taxonomy Name | Oral and Maxillofacial Surgery Clinic/Center
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License Number | MD60336798
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 261QS0112X
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Taxonomy Name | Oral and Maxillofacial Surgery Clinic/Center
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License Number | D9077
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License Number State | OR
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Taxonomy #3
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Taxonomy Code | 261QS0112X
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Taxonomy Name | Oral and Maxillofacial Surgery Clinic/Center
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License Number | DE60337452
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License Number State | WA
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