1245544824 NPI number — LAKE MICHIGAN ORAL & MAXILLOFACIAL SURGERY PLLC

Table of content: (NPI 1245544824)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245544824 NPI number — LAKE MICHIGAN ORAL & MAXILLOFACIAL SURGERY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE MICHIGAN ORAL & MAXILLOFACIAL SURGERY PLLC
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:
1245544824
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/05/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3000 UNITED FOUNDERS BLVD
Provider Second Line Business Mailing Address:
237
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73112-3958
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-848-7974
Provider Business Mailing Address Fax Number:
405-848-0033

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3950 HOLLYWOOD RD
Provider Second Line Business Practice Location Address:
290
Provider Business Practice Location Address City Name:
SAINT JOSEPH
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49085-9151
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-848-7974
Provider Business Practice Location Address Fax Number:
405-848-0033
Provider Enumeration Date:
08/05/2010

Additional Information

Authorized Official

Authorized Official Last Name:
KEOUGH
Authorized Official First Name:
LISA
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING REP
Authorized Official Telephone Number:
405-848-7974

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  2901018748 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com