Provider Demographics
NPI:1124540240
Name:CENTRAL MICHIGAN GROUP
Entity Type:Organization
Organization Name:CENTRAL MICHIGAN GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOESPH
Authorized Official - Middle Name:VINCENT
Authorized Official - Last Name:MAURO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:517-272-0886
Mailing Address - Street 1:231 W LAKE LANSING RD STE 200
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-8451
Mailing Address - Country:US
Mailing Address - Phone:517-272-0886
Mailing Address - Fax:517-272-0887
Practice Address - Street 1:231 W LAKE LANSING RD STE 200
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-8451
Practice Address - Country:US
Practice Address - Phone:517-272-0886
Practice Address - Fax:517-272-0887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJM012412261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5330109OtherBLUE CROSS BLUE SHIELD OF MICHIGAN