Provider Demographics
NPI:1801644042
Name:GREAT LAKES ORAL SURGERY PLLC
Entity type:Organization
Organization Name:GREAT LAKES ORAL SURGERY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:DEUEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:269-845-0671
Mailing Address - Street 1:2265 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-5830
Mailing Address - Country:US
Mailing Address - Phone:269-845-0671
Mailing Address - Fax:
Practice Address - Street 1:955 W EISENHOWER CIR STE G
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-5868
Practice Address - Country:US
Practice Address - Phone:269-845-0671
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-13
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty