Provider Demographics
NPI:1245544824
Name:LAKE MICHIGAN ORAL & MAXILLOFACIAL SURGERY PLLC
Entity type:Organization
Organization Name:LAKE MICHIGAN ORAL & MAXILLOFACIAL SURGERY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING REP
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:KEOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-848-7974
Mailing Address - Street 1:3000 UNITED FOUNDERS BLVD
Mailing Address - Street 2:237
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-3958
Mailing Address - Country:US
Mailing Address - Phone:405-848-7974
Mailing Address - Fax:405-848-0033
Practice Address - Street 1:3950 HOLLYWOOD RD
Practice Address - Street 2:290
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-9151
Practice Address - Country:US
Practice Address - Phone:405-848-7974
Practice Address - Fax:405-848-0033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-05
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010187481223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty