1710127188 NPI number — OAKLAND ORAL SURGERY ASSOCIATES

Table of content: (NPI 1710127188)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710127188 NPI number — OAKLAND ORAL SURGERY ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OAKLAND ORAL SURGERY ASSOCIATES
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:
1710127188
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/25/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
31646 SCHOOLCRAFT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LIVONIA
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48150-1819
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-427-3366
Provider Business Mailing Address Fax Number:
734-427-0407

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
31646 SCHOOLCRAFT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LIVONIA
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48150-1819
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-427-3366
Provider Business Practice Location Address Fax Number:
734-427-0407
Provider Enumeration Date:
02/25/2009

Additional Information

Authorized Official

Authorized Official Last Name:
MOORES
Authorized Official First Name:
JACK
Authorized Official Middle Name:
F
Authorized Official Title or Position:
ORAL AND MAXILLOFACIAL SURGEON
Authorized Official Telephone Number:
734-427-3366

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  JM16423 , 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)

  • Identifier: P13950001 . This is a "MEDICARE INDIVIDUAL PTAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: P13950004 . This is a "MEDICARE INDIVIDUAL PTAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0P13950 . This is a "MEDICARE GROUP PTAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: P13950003 . This is a "MEDICARE INDIVIDUAL PTAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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