Healthcare Provider Details

I. General information

NPI: 1477395119
Provider Name (Legal Business Name): DETROIT ORAL SURGERY SPECIALISTS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2024
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13874 GRAND RIVER AVE
DETROIT MI
48227-3123
US

IV. Provider business mailing address

27201 RYAN RD
WARREN MI
48092-5127
US

V. Phone/Fax

Practice location:
  • Phone: 313-834-4900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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: ALEX WOLICKI
Title or Position: ACCOUNTANT
Credential:
Phone: 586-558-8004