Healthcare Provider Details

I. General information

NPI: 1669675567
Provider Name (Legal Business Name): ORAL AND MAXILLOFACIAL SURGERY ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

785 E M32
GAYLORD MI
49735
US

IV. Provider business mailing address

785 E M32
GAYLORD MI
49735
US

V. Phone/Fax

Practice location:
  • Phone: 989-732-1727
  • Fax: 989-732-1728
Mailing address:
  • Phone: 989-732-1727
  • Fax: 989-732-1728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number2901010349
License Number StateMI

VIII. Authorized Official

Name: MICHAEL JAMES MOIR
Title or Position: SURGEON
Credential: DDS
Phone: 989-732-1727