Healthcare Provider Details

I. General information

NPI: 1972777514
Provider Name (Legal Business Name): DEARBORN ORAL & MAXILLOFACIAL SURGERY ASSOCIATES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2008
Last Update Date: 04/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 MONROE ST
DEARBORN MI
48124-2923
US

IV. Provider business mailing address

2120 MONROE ST
DEARBORN MI
48124-2923
US

V. Phone/Fax

Practice location:
  • Phone: 313-562-5800
  • Fax: 313-562-6418
Mailing address:
  • Phone: 313-562-5800
  • Fax: 313-562-6418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number4301069256
License Number StateMI

VIII. Authorized Official

Name: DR. BRIAN H COHEN
Title or Position: PRESIDENT
Credential: D.D.S., M.D.
Phone: 313-562-5800