Provider Demographics
NPI:1841862232
Name:LEGACY ORAL AND FACIAL SURGERY CENTER PC
Entity type:Organization
Organization Name:LEGACY ORAL AND FACIAL SURGERY CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DALBERT
Authorized Official - Middle Name:W
Authorized Official - Last Name:FEAR
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS,MS
Authorized Official - Phone:734-395-9532
Mailing Address - Street 1:3706 CREEKSIDE CT
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9570
Mailing Address - Country:US
Mailing Address - Phone:734-395-9532
Mailing Address - Fax:740-919-5871
Practice Address - Street 1:2521 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-3818
Practice Address - Country:US
Practice Address - Phone:734-210-0677
Practice Address - Fax:734-210-1273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery