Provider Demographics
NPI:1295375137
Name:ORAL & MAXILLOFACIAL SURGERY OF GREATER GRAND RAPIDS LLC
Entity Type:Organization
Organization Name:ORAL & MAXILLOFACIAL SURGERY OF GREATER GRAND RAPIDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY G VANHOOSE
Authorized Official - Middle Name:GARRETT
Authorized Official - Last Name:VANHOOSE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:616-891-1700
Mailing Address - Street 1:9021 N RODGERS CT SE STE A
Mailing Address - Street 2:
Mailing Address - City:CALEDONIA
Mailing Address - State:MI
Mailing Address - Zip Code:49316-7650
Mailing Address - Country:US
Mailing Address - Phone:616-891-1700
Mailing Address - Fax:616-891-9306
Practice Address - Street 1:9021 N RODGERS CT SE STE A
Practice Address - Street 2:
Practice Address - City:CALEDONIA
Practice Address - State:MI
Practice Address - Zip Code:49316-7650
Practice Address - Country:US
Practice Address - Phone:616-891-1700
Practice Address - Fax:616-891-9306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-08
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1134177942OtherNPI