Provider Demographics
NPI:1609916667
Name:NORTH COAST ORAL & MAXILLOFACIAL SURGERY, INC.
Entity Type:Organization
Organization Name:NORTH COAST ORAL & MAXILLOFACIAL SURGERY, INC.
Other - Org Name:MARIANNE L. COBURN, D.D.S., TERENCE P. KELLY, D.D.S., & JOHN HELMKAMP,
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TERENCE
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:419-627-8131
Mailing Address - Street 1:2500 W. STRUB RD.
Mailing Address - Street 2:NOMS PROFESSIONAL BLDG. #1
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870
Mailing Address - Country:US
Mailing Address - Phone:419-627-8131
Mailing Address - Fax:419-621-1773
Practice Address - Street 1:2500 W. STRUB RD.
Practice Address - Street 2:NOMS PROFESSIONAL BLDG. #1
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870
Practice Address - Country:US
Practice Address - Phone:419-627-8131
Practice Address - Fax:419-621-1773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2089789Medicaid
OHMA9306411Medicare ID - Type Unspecified