Provider Demographics
NPI:1003095605
Name:GRAND TRAVERSE ORAL SURGERY, P.C.
Entity Type:Organization
Organization Name:GRAND TRAVERSE ORAL SURGERY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:SCHLUETER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-946-3512
Mailing Address - Street 1:12776 S WEST BAY SHORE DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-5451
Mailing Address - Country:US
Mailing Address - Phone:231-946-3512
Mailing Address - Fax:231-946-1908
Practice Address - Street 1:12776 S WEST BAY SHORE DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-5451
Practice Address - Country:US
Practice Address - Phone:231-946-3512
Practice Address - Fax:231-946-1908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P21110OtherMEDICARE GROUP #