1235325499 NPI number — RENAISSANCE ORAL SURGERY PC

Table of content: (NPI 1235325499)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235325499 NPI number — RENAISSANCE ORAL SURGERY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RENAISSANCE ORAL SURGERY PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235325499
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/01/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20805 E 12 MILE RD
Provider Second Line Business Mailing Address:
STE 110
Provider Business Mailing Address City Name:
ROSEVILLE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48066
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-778-2100
Provider Business Mailing Address Fax Number:
586-778-2422

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20805 E 12 MILE RD
Provider Second Line Business Practice Location Address:
STE 110
Provider Business Practice Location Address City Name:
ROSEVILLE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48066
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-778-2100
Provider Business Practice Location Address Fax Number:
586-778-2422
Provider Enumeration Date:
09/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BRYAN
Authorized Official First Name:
HENRY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
586-778-2100

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 204E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2082S0099X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 975506164 . This is a "BC/BS MEDICARE ADVANTAGE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: U33701 . This is a "HAP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 2856 . This is a "GOLDEN DENTAL" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 128744 . This is a "CARE CHOICES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 975506164 . This is a "BC/BS OF MI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: P00230001 . This is a "MEDICARE PROVIDER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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