Provider Demographics
NPI:1265522262
Name:KALAMAZOO ORAL & MAXILLOFACIAL SURGERY, P.C.
Entity type:Organization
Organization Name:KALAMAZOO ORAL & MAXILLOFACIAL SURGERY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMONELLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-323-1527
Mailing Address - Street 1:3801 GLENKERRY CT
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-0718
Mailing Address - Country:US
Mailing Address - Phone:269-323-1527
Mailing Address - Fax:269-323-1670
Practice Address - Street 1:3801 GLENKERRY CT
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-0718
Practice Address - Country:US
Practice Address - Phone:269-323-1527
Practice Address - Fax:269-323-1670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1669433793OtherTYPE 1 NPI T. SLACK
1376705038OtherTYPE 1 NPI D. WILSON
1164416194OtherTYPE 1 NPI K. MORSE
1952361594OtherTYPE 1 NPI C. KANAR
1780645804OtherTYPE 1 NPI J. GISSAL