Provider Demographics
NPI:1689848004
Name:JEROME, WILLIAM F (DDS, MS)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:F
Last Name:JEROME
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9448 STONEBROOK
Mailing Address - Street 2:
Mailing Address - City:CHARLEVOIX
Mailing Address - State:MI
Mailing Address - Zip Code:49720-2081
Mailing Address - Country:US
Mailing Address - Phone:231-547-5470
Mailing Address - Fax:
Practice Address - Street 1:9448 STONEBROOK
Practice Address - Street 2:
Practice Address - City:CHARLEVOIX
Practice Address - State:MI
Practice Address - Zip Code:49720-2081
Practice Address - Country:US
Practice Address - Phone:231-547-5470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010085851223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIJ085850OtherBCBSM PIN
MI2901008585OtherDENTISTRY LICENSE
MI2901008585OtherSPECIALTY CERTIFICATION
MI2901008585OtherCONTROLLED SUBSTANCE LIC
MIAJ3082031OtherDEA LICENSE
MIAJ3082031OtherDEA LICENSE