Provider Demographics
NPI:1922261783
Name:JEFFREY S. COHEN DDS PC
Entity Type:Organization
Organization Name:JEFFREY S. COHEN DDS PC
Other - Org Name:LAKES ORAL AND MAXILLOFACIAL SURGERY PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FRONT OFFICE SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:FETTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-669-6600
Mailing Address - Street 1:2300 HAGGERTY RD
Mailing Address - Street 2:SUITE 2030
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48323-2184
Mailing Address - Country:US
Mailing Address - Phone:248-669-6600
Mailing Address - Fax:248-669-6606
Practice Address - Street 1:2300 HAGGERTY RD
Practice Address - Street 2:SUITE 2030
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48323-2184
Practice Address - Country:US
Practice Address - Phone:248-669-6600
Practice Address - Fax:248-669-6606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-02
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJC07120174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P23970Medicare PIN