Provider Demographics
NPI:1245253111
Name:PLYMOUTH ORAL & FACIAL SURGERY, PLC
Entity type:Organization
Organization Name:PLYMOUTH ORAL & FACIAL SURGERY, PLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:H
Authorized Official - Last Name:STURTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:734-455-0710
Mailing Address - Street 1:9416 S MAIN ST
Mailing Address - Street 2:SUITE 211
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-4157
Mailing Address - Country:US
Mailing Address - Phone:734-455-0710
Mailing Address - Fax:734-455-4433
Practice Address - Street 1:9416 S MAIN ST
Practice Address - Street 2:SUITE 211
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-4157
Practice Address - Country:US
Practice Address - Phone:734-455-0710
Practice Address - Fax:734-455-4433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010176351223S0112X
MI29010128521223S0112X
MI29010119931223S0112X
MI29010143831223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN59700001Medicare UPIN
MIN59700002Medicare UPIN
MIN59700003Medicare UPIN
MION59700Medicare ID - Type UnspecifiedPROVIDER ID