Provider Demographics
NPI:1720262348
Name:BLOOMFIELD ORAL & MAXILLOFACIAL SURGERY, P.C.
Entity Type:Organization
Organization Name:BLOOMFIELD ORAL & MAXILLOFACIAL SURGERY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:DANA
Authorized Official - Last Name:CHESLIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,MD
Authorized Official - Phone:248-647-1422
Mailing Address - Street 1:50 W BIG BEAVER RD
Mailing Address - Street 2:SUITE 190
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-3910
Mailing Address - Country:US
Mailing Address - Phone:248-647-1422
Mailing Address - Fax:248-647-6117
Practice Address - Street 1:50 W BIG BEAVER RD
Practice Address - Street 2:SUITE 190
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304-3910
Practice Address - Country:US
Practice Address - Phone:248-647-1422
Practice Address - Fax:248-647-6117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-18
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOMO1350Medicare PIN