Provider Demographics
NPI:1588618912
Name:CADILLAC ORAL SURGERY ASSOC
Entity type:Organization
Organization Name:CADILLAC ORAL SURGERY ASSOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:S
Authorized Official - Last Name:VANDERHOOF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-775-1268
Mailing Address - Street 1:855 S CARMEL ST
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-2383
Mailing Address - Country:US
Mailing Address - Phone:231-775-1268
Mailing Address - Fax:231-775-1190
Practice Address - Street 1:855 S CARMEL ST
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-2344
Practice Address - Country:US
Practice Address - Phone:231-775-1268
Practice Address - Fax:231-775-1190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0H36003Medicare PIN