Healthcare Provider Details

I. General information

NPI: 1427835792
Provider Name (Legal Business Name): BLOOMFIELD ORAL & MAXILLOFACIAL SURGERY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2023
Last Update Date: 03/12/2024
Certification Date: 03/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 BLOOMFIELD HILLS PKWY STE 100
BLOOMFIELD HILLS MI
48304-2945
US

IV. Provider business mailing address

33 BLOOMFIELD HILLS PKWY STE 100
BLOOMFIELD HILLS MI
48304-2945
US

V. Phone/Fax

Practice location:
  • Phone: 248-877-1126
  • Fax:
Mailing address:
  • Phone: 248-341-8477
  • Fax: 248-341-8479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. GARY FORGACH
Title or Position: OWNER
Credential: DDS
Phone: 248-877-1126