Provider Demographics
NPI:1154483014
Name:NORTHERN MICHIGAN ORAL AND MAXILLOFACIAL SURGERY PC
Entity Type:Organization
Organization Name:NORTHERN MICHIGAN ORAL AND MAXILLOFACIAL SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:OSETEK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:231-347-1601
Mailing Address - Street 1:322 BAY ST
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-2489
Mailing Address - Country:US
Mailing Address - Phone:231-347-1601
Mailing Address - Fax:
Practice Address - Street 1:322 BAY ST
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-2489
Practice Address - Country:US
Practice Address - Phone:231-347-1601
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010132551223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1174507495OtherNPI INDIVIDUAL
MI1003892944OtherNPI INDIVIDUAL
MI1174507495OtherNPI INDIVIDUAL
MI1174507495OtherNPI INDIVIDUAL