Provider Demographics
NPI:1275640369
Name:ORAL AND FACIAL SURGEONS OF MICHIGAN, PC
Entity Type:Organization
Organization Name:ORAL AND FACIAL SURGEONS OF MICHIGAN, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING DEPT./ACCOUNTS
Authorized Official - Prefix:MRS
Authorized Official - First Name:EVELYN
Authorized Official - Middle Name:M
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-632-0303
Mailing Address - Street 1:11525 HIGHLAND RD
Mailing Address - Street 2:SUITE 23
Mailing Address - City:HARTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48353-2726
Mailing Address - Country:US
Mailing Address - Phone:810-632-0303
Mailing Address - Fax:810-632-7305
Practice Address - Street 1:11525 HIGHLAND RD
Practice Address - Street 2:SUITE 23
Practice Address - City:HARTLAND
Practice Address - State:MI
Practice Address - Zip Code:48353-2726
Practice Address - Country:US
Practice Address - Phone:810-632-0303
Practice Address - Fax:810-632-7305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2022-07-21
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
MI190F37120OtherBCBS OF MI
MION78470Medicare ID - Type Unspecified
MIOF37120Medicare ID - Type Unspecified