Provider Demographics
NPI:1053458604
Name:WEST SHORE ORAL & MAXILLOFACIAL SURGERY ASSOCIATES, PLC
Entity Type:Organization
Organization Name:WEST SHORE ORAL & MAXILLOFACIAL SURGERY ASSOCIATES, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:T
Authorized Official - Last Name:BURYE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:231-733-1571
Mailing Address - Street 1:5957 HARVEY ST STE 200
Mailing Address - Street 2:
Mailing Address - City:NORTON SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:49444-6735
Mailing Address - Country:US
Mailing Address - Phone:231-733-1571
Mailing Address - Fax:231-733-5228
Practice Address - Street 1:5957 HARVEY ST
Practice Address - Street 2:
Practice Address - City:NORTON SHORES
Practice Address - State:MI
Practice Address - Zip Code:49444-9737
Practice Address - Country:US
Practice Address - Phone:231-733-1571
Practice Address - Fax:231-733-5228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIB7708N1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M98340Medicare ID - Type Unspecified