Provider Demographics
NPI:1508324732
Name:ADVANCED ORAL SURGERY, PLLC
Entity Type:Organization
Organization Name:ADVANCED ORAL SURGERY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:LEONARD
Authorized Official - Last Name:JESIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:616-369-0360
Mailing Address - Street 1:3855 BURTON ST SE STE B
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-6147
Mailing Address - Country:US
Mailing Address - Phone:616-369-0360
Mailing Address - Fax:616-369-0361
Practice Address - Street 1:3855 BURTON ST SE STE B
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6147
Practice Address - Country:US
Practice Address - Phone:616-369-0360
Practice Address - Fax:616-369-0361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-06
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty