Provider Demographics
NPI:1598772626
Name:ORAL & MAXILLOFACIAL SURGERY ASSOCIATES OF WESTERN MICHIGAN PLC
Entity Type:Organization
Organization Name:ORAL & MAXILLOFACIAL SURGERY ASSOCIATES OF WESTERN MICHIGAN PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:J
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:DOMIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:616-791-9600
Mailing Address - Street 1:2140 LAKE MICHIGAN DR NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-4785
Mailing Address - Country:US
Mailing Address - Phone:616-791-9600
Mailing Address - Fax:616-791-9603
Practice Address - Street 1:2140 LAKE MICHIGAN DR NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49504-4785
Practice Address - Country:US
Practice Address - Phone:616-791-9600
Practice Address - Fax:616-791-9603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
970D111530OtherBCBSM BCN/CHOICE
CC0861OtherMEDICARE RAILROAD
MI0N13750OtherMEDICARE GROUP NUMBER