Provider Demographics
NPI:1801906458
Name:MICHIGAN OMS P C
Entity type:Organization
Organization Name:MICHIGAN OMS P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:BOURNIAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:586-228-9070
Mailing Address - Street 1:6022 W MAPLE RD STE 405
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-4408
Mailing Address - Country:US
Mailing Address - Phone:248-855-2006
Mailing Address - Fax:248-855-0571
Practice Address - Street 1:6022 W MAPLE RD STE 405
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-4408
Practice Address - Country:US
Practice Address - Phone:248-855-2006
Practice Address - Fax:248-855-0571
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2024-01-17
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
MI2901020355OtherSTATE LICENSE NUMBER
MI3159052Medicaid
MI4067429Medicaid
MI2990516Medicaid
MI2990561Medicaid
MI2773480Medicaid
MI970F31085OtherGROUP NUMBER BCBSM
MINB015573OtherSTATE LICENSE NUMBER
MI1021382Medicaid
MI3203473Medicaid
MI2990552Medicaid
MI4067429Medicaid
MIJH013563OtherSTATE LICENSE NUMBER
MIJT009517OtherSTATE LICENSE NUMBER
MI1021382Medicaid
MI2990552Medicaid
MI3159052Medicaid
MI2990561Medicaid
MIT96879Medicare UPIN