Provider Demographics
NPI:1174858419
Name:GREAT LAKES ORAL SURGERY, P.C.
Entity Type:Organization
Organization Name:GREAT LAKES ORAL SURGERY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:MACGREGOR
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:315-343-6160
Mailing Address - Street 1:633 W. 3RD ST. S.
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:NY
Mailing Address - Zip Code:13069
Mailing Address - Country:US
Mailing Address - Phone:315-343-6160
Mailing Address - Fax:315-343-8556
Practice Address - Street 1:633 W. 3RD ST. S.
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:NY
Practice Address - Zip Code:13069
Practice Address - Country:US
Practice Address - Phone:315-343-6160
Practice Address - Fax:315-343-8556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-05
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0515941223S0112X
1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03118614Medicaid