Provider Demographics
NPI:1861650095
Name:MID MICHIGAN ORAL SURGERY
Entity Type:Organization
Organization Name:MID MICHIGAN ORAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL SURGEON / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:E
Authorized Official - Last Name:BECKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:517-337-9759
Mailing Address - Street 1:110 N COCHRAN AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48813-1508
Mailing Address - Country:US
Mailing Address - Phone:517-337-9759
Mailing Address - Fax:517-337-8156
Practice Address - Street 1:110 N COCHRAN AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:MI
Practice Address - Zip Code:48813-1508
Practice Address - Country:US
Practice Address - Phone:517-337-9759
Practice Address - Fax:517-337-8156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-23
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M18080Medicare PIN