Provider Demographics
NPI:1598255044
Name:BIRMINGHAM ORAL & MAXILLOFACIAL SURGERY, PLC
Entity Type:Organization
Organization Name:BIRMINGHAM ORAL & MAXILLOFACIAL SURGERY, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCNAUGHTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:486-474-7002
Mailing Address - Street 1:555 S OLD WOODWARD AVE STE 777
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-6618
Mailing Address - Country:US
Mailing Address - Phone:248-647-4700
Mailing Address - Fax:248-647-4730
Practice Address - Street 1:555 S OLD WOODWARD AVE STE 777
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009
Practice Address - Country:US
Practice Address - Phone:248-647-4700
Practice Address - Fax:248-647-4730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-10
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010129811223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2990516Medicaid