Provider Demographics
NPI:1811066129
Name:SUMMIT ORAL & MAXILLOFACIAL SURGERY PC
Entity type:Organization
Organization Name:SUMMIT ORAL & MAXILLOFACIAL SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SPECIALIST
Authorized Official - Prefix:MS
Authorized Official - First Name:JANE
Authorized Official - Middle Name:M
Authorized Official - Last Name:WINDISCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-755-9340
Mailing Address - Street 1:29425 RYAN RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-2203
Mailing Address - Country:US
Mailing Address - Phone:586-755-9340
Mailing Address - Fax:586-755-9341
Practice Address - Street 1:29427 RYAN RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-2203
Practice Address - Country:US
Practice Address - Phone:586-755-9340
Practice Address - Fax:586-755-9341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI970E076800OtherBC
MI0E07680OtherMEDICARE PTAN
MI0E07680OtherMEDICARE PTAN