Provider Demographics
NPI:1619964715
Name:MIDLAND ORAL & MAXILLOFACIAL SURGERY P.C.
Entity Type:Organization
Organization Name:MIDLAND ORAL & MAXILLOFACIAL SURGERY P.C.
Other - Org Name:MT. PLEASANT ORAL & MAXILLOFACIAL SURGERY
Other - Org Type:Other Name
Authorized Official - Title/Position:FINANCIAL DEPT
Authorized Official - Prefix:
Authorized Official - First Name:SHIANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOWERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-839-9979
Mailing Address - Street 1:6112 MERLIN CT
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-7358
Mailing Address - Country:US
Mailing Address - Phone:989-839-9979
Mailing Address - Fax:989-839-9553
Practice Address - Street 1:6112 MERLIN CT
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640
Practice Address - Country:US
Practice Address - Phone:989-839-9979
Practice Address - Fax:989-839-9553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-04
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
204E00000X
MIRP0164021223S0112X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2993779Medicaid
MI4274317Medicaid
MI4285455Medicaid
MI3487124Medicaid
MI4263986Medicaid
MI2847912Medicaid
MI4274291Medicaid
MI4274282Medicaid
MI4274308Medicaid
MI3487133Medicaid
MI426977Medicaid
MI4297311Medicaid
MI2993779Medicaid
MI4274308Medicaid
MI3487133Medicaid
MI4274291Medicaid
MI426977Medicaid
MI4263986Medicaid