Provider Demographics
NPI:1326291816
Name:GREAT LAKES JAW SURGERY, PC
Entity Type:Organization
Organization Name:GREAT LAKES JAW SURGERY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ ORAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:ROSEMA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:616-281-2370
Mailing Address - Street 1:2017 EASTCASTLE DR SE
Mailing Address - Street 2:SUITE C
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508-8872
Mailing Address - Country:US
Mailing Address - Phone:616-281-2370
Mailing Address - Fax:616-281-2801
Practice Address - Street 1:2017 EASTCASTLE DR SE
Practice Address - Street 2:SUITE C
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-8872
Practice Address - Country:US
Practice Address - Phone:616-281-2370
Practice Address - Fax:616-281-2801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-28
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010113451223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI10-2978271Medicaid
MI10-2978271Medicaid
MIOM10820Medicare PIN