Provider Demographics
NPI:1487183000
Name:SOUTH SOUND AMBULATORY SURGERY CENTER, PLLC
Entity type:Organization
Organization Name:SOUTH SOUND AMBULATORY SURGERY CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:C
Authorized Official - Last Name:MULREAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:360-456-5678
Mailing Address - Street 1:3425 ENSIGN RD NE STE 310
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5063
Mailing Address - Country:US
Mailing Address - Phone:360-456-5678
Mailing Address - Fax:360-456-1238
Practice Address - Street 1:3425 ENSIGN RD NE STE 310
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5063
Practice Address - Country:US
Practice Address - Phone:360-456-5678
Practice Address - Fax:360-456-1238
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTH SOUND ORAL SURGERY PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-06-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QS0112X
WA601803289204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
No261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial SurgeryGroup - Single Specialty