Provider Demographics
NPI:1437381753
Name:TAHOE ORAL AND MAXILLOFACIAL SURGERY
Entity type:Organization
Organization Name:TAHOE ORAL AND MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF BILLING
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:DRESHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-848-7974
Mailing Address - Street 1:12277 SOARING WAY
Mailing Address - Street 2:SUITE 103
Mailing Address - City:TRUCKEE
Mailing Address - State:CA
Mailing Address - Zip Code:96161-3320
Mailing Address - Country:US
Mailing Address - Phone:405-848-7974
Mailing Address - Fax:405-848-0033
Practice Address - Street 1:5600 N MAY AVE
Practice Address - Street 2:SUITE 250
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-3973
Practice Address - Country:US
Practice Address - Phone:405-848-7974
Practice Address - Fax:405-848-0033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-20
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA546651223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty