Provider Demographics
NPI:1760008528
Name:GREAT LAKES ORAL AND MAXILLOFACIAL SURGERY P.C.
Entity Type:Organization
Organization Name:GREAT LAKES ORAL AND MAXILLOFACIAL SURGERY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:SHEPERD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:231-487-1020
Mailing Address - Street 1:2325 SUMMIT PARK DR STE D
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-8774
Mailing Address - Country:US
Mailing Address - Phone:231-487-1020
Mailing Address - Fax:
Practice Address - Street 1:2325 SUMMIT PARK DR STE D
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-8774
Practice Address - Country:US
Practice Address - Phone:231-487-1020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-17
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty