Provider Demographics
NPI:1326197880
Name:WEST MICHIGAN ORAL AND MAXILLOFACIAL SURGERY PC
Entity Type:Organization
Organization Name:WEST MICHIGAN ORAL AND MAXILLOFACIAL SURGERY PC
Other - Org Name:WEST MICHIGAN ORAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY TREASURER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:LINDHOUT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,M,S
Authorized Official - Phone:616-530-4710
Mailing Address - Street 1:601 MICHIGAN AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-4951
Mailing Address - Country:US
Mailing Address - Phone:616-530-4710
Mailing Address - Fax:616-530-0480
Practice Address - Street 1:601 MICHIGAN AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-4951
Practice Address - Country:US
Practice Address - Phone:616-530-4710
Practice Address - Fax:616-530-0480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0G06047Medicare PIN
CK4964Medicare PIN