Healthcare Provider Details

I. General information

NPI: 1366244550
Provider Name (Legal Business Name): CTA ORAL PATHOLOGY CONSULTANTS OF MICHIGAN PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2025
Last Update Date: 04/28/2025
Certification Date: 04/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3131 S STATE ST STE 309
ANN ARBOR MI
48108-1658
US

IV. Provider business mailing address

PO BOX 230457
PORTLAND OR
97281-0457
US

V. Phone/Fax

Practice location:
  • Phone: 503-906-7300
  • Fax: 503-245-8219
Mailing address:
  • Phone: 503-906-7300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number
License Number State

VIII. Authorized Official

Name: BRENT ACCURSO
Title or Position: SOLE MEMBER
Credential: DDS
Phone: 734-709-5326