Healthcare Provider Details

I. General information

NPI: 1528008042
Provider Name (Legal Business Name): MICHIGAN ORAL AND MAXILLOFACIAL SURGEONS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 09/02/2025
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2058 S STATE ST STE 100
ANN ARBOR MI
48104-4787
US

IV. Provider business mailing address

2058 S STATE ST SUITE 100
ANN ARBOR MI
48104-4786
US

V. Phone/Fax

Practice location:
  • Phone: 734-769-5302
  • Fax: 734-769-8710
Mailing address:
  • Phone: 734-769-6524
  • Fax: 734-769-6743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: SARAH TYLER SEMINARA
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 734-459-0326