Provider Demographics
NPI:1629445986
Name:WESTERN LAKE ERIE OMS, PC
Entity Type:Organization
Organization Name:WESTERN LAKE ERIE OMS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:VORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-243-9160
Mailing Address - Street 1:876 STEWART RD
Mailing Address - Street 2:#3
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-5345
Mailing Address - Country:US
Mailing Address - Phone:734-243-9160
Mailing Address - Fax:734-243-6393
Practice Address - Street 1:876 STEWART RD
Practice Address - Street 2:#3
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-5345
Practice Address - Country:US
Practice Address - Phone:734-243-9160
Practice Address - Fax:734-243-6393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-21
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1223S0112X
261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty