1528008042 NPI number — MICHIGAN ORAL AND MAXILLOFACIAL SURGEONS, P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528008042 NPI number — MICHIGAN ORAL AND MAXILLOFACIAL SURGEONS, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHIGAN ORAL AND MAXILLOFACIAL SURGEONS, P.C.
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:
6
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:
1528008042
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/18/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2058 S STATE ST
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
ANN ARBOR
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48104-4786
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-769-6524
Provider Business Mailing Address Fax Number:
734-769-6743

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2058 S STATE ST STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANN ARBOR
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48104-4787
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-769-5302
Provider Business Practice Location Address Fax Number:
734-769-8710
Provider Enumeration Date:
06/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SEMINARA
Authorized Official First Name:
SARAH
Authorized Official Middle Name:
TYLER
Authorized Official Title or Position:
CREDENTIALING SPECIALIST
Authorized Official Telephone Number:
734-459-0326

Provider Taxonomy Codes

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

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

  • Identifier: J801610 . This is a "BCBS DENTAL GROUP #" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 970H17622 . This is a "BCBS GROUP NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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