Provider Demographics
NPI:1710127188
Name:OAKLAND ORAL SURGERY ASSOCIATES
Entity Type:Organization
Organization Name:OAKLAND ORAL SURGERY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL AND MAXILLOFACIAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:F
Authorized Official - Last Name:MOORES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:734-427-3366
Mailing Address - Street 1:31646 SCHOOLCRAFT RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-1819
Mailing Address - Country:US
Mailing Address - Phone:734-427-3366
Mailing Address - Fax:734-427-0407
Practice Address - Street 1:31646 SCHOOLCRAFT RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-1819
Practice Address - Country:US
Practice Address - Phone:734-427-3366
Practice Address - Fax:734-427-0407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-25
Last Update Date:2009-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJM164231223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP13950001OtherMEDICARE INDIVIDUAL PTAN
MIP13950004OtherMEDICARE INDIVIDUAL PTAN
MI0P13950OtherMEDICARE GROUP PTAN
MIP13950003OtherMEDICARE INDIVIDUAL PTAN
MIOM93350Medicare PIN
MIP13950004OtherMEDICARE INDIVIDUAL PTAN
U99142Medicare UPIN
MIU50526Medicare UPIN
MI0P13950OtherMEDICARE GROUP PTAN
MIU78530Medicare UPIN
MIP13950001OtherMEDICARE INDIVIDUAL PTAN