# EVERGREEN ORAL SURGERY

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1811586761
- **Authorized official:** ANGIE MINKS (CREDENTIALING SPECIALIST)
- **Authorized official phone:** (740) 243-6241

## Contact information

- **Practice address:** 6050 TACOMA MALL BLVD STE 330, TACOMA, WA 98409-6811
- **Practice address phone:** (253) 473-0651
- **Practice address fax:** (253) 444-0761
- **Mailing address:** 13894 SUNLADEN CT, PICKERINGTON, OH 43147-8216
- **Mailing address phone:** (740) 243-6241
- **Mailing address fax:** (740) 919-5871

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 204E00000X | Oral & Maxillofacial Surgery (D.M.D.) | — | NULL | Yes |
| 204E00000X | Oral & Maxillofacial Surgery (D.M.D.) | — | — | Yes |

## Other

- **Enumeration date:** 01/14/2021
- **Last updated:** 01/14/2021