MEDICARE: SOUTH SOUND AMBULATORY SURGERY CENTER, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QS0112X	Oral and Maxillofacial Surgery Clinic/Center
2	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)	601803289	WA

General Provider Information

NPI Number	:	1487183000
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH SOUND AMBULATORY SURGERY CENTER, PLLC

Provider Business Mailing Address
First Line	:	3425 ENSIGN RD NE STE 310
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98506-5063
Country	:	US
Telephone Number	:	360-456-5678
Fax Number	:	360-456-1238

Provider Business Practice Location Address
First Line	:	3425 ENSIGN RD NE STE 310
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98506-5063
Country	:	US
Telephone Number	:	360-456-5678
Fax Number	:	360-456-1238

Authorized Official
Title or Position	:	CO-OWNER
Name	:	JOSEPH C MULREAN
Credential	:	DMD
Telephone Number	:	360-456-5678

Provider Enumeration Date	:	06/07/2017
Last Update Date	:	07/21/2022

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