Provider Demographics
NPI:1235325499
Name:RENAISSANCE ORAL SURGERY PC
Entity Type:Organization
Organization Name:RENAISSANCE ORAL SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRYAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:586-778-2100
Mailing Address - Street 1:20805 E 12 MILE RD
Mailing Address - Street 2:STE 110
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066
Mailing Address - Country:US
Mailing Address - Phone:586-778-2100
Mailing Address - Fax:586-778-2422
Practice Address - Street 1:20805 E 12 MILE RD
Practice Address - Street 2:STE 110
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066
Practice Address - Country:US
Practice Address - Phone:586-778-2100
Practice Address - Fax:586-778-2422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-21
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
No2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and NeckGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI975506164OtherBC/BS MEDICARE ADVANTAGE
MIU33701OtherHAP
MI2856OtherGOLDEN DENTAL
MI128744OtherCARE CHOICES
MI975506164OtherBC/BS OF MI
MIP00230001OtherMEDICARE PROVIDER
MIP00230001OtherMEDICARE PROVIDER