Healthcare Provider Details

I. General information

NPI: 1427457191
Provider Name (Legal Business Name): KEYSTONE ORAL AND MAXILLOFACIAL SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2014
Last Update Date: 10/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36975 UTICA RD SUITE 106
CLINTON TOWNSHIP MI
48036-1685
US

IV. Provider business mailing address

36975 UTICA RD SUITE 106
CLINTON TOWNSHIP MI
48036-1685
US

V. Phone/Fax

Practice location:
  • Phone: 586-226-2801
  • Fax: 586-226-1519
Mailing address:
  • Phone: 586-226-2801
  • Fax: 586-226-1519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2901017390
License Number StateMI

VIII. Authorized Official

Name: MR. ANTHONY E KASPER
Title or Position: OWNER
Credential: DDS
Phone: 586-914-0093