Healthcare Provider Details

I. General information

NPI: 1033594411
Provider Name (Legal Business Name): PREMIER ORAL SURGERY AND IMPLANTS, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2015
Last Update Date: 10/29/2020
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5090 E HILL RD
GRAND BLANC MI
48439-7637
US

IV. Provider business mailing address

5090 E HILL RD
GRAND BLANC MI
48439-7637
US

V. Phone/Fax

Practice location:
  • Phone: 810-445-9970
  • Fax: 810-445-9971
Mailing address:
  • Phone: 810-445-9970
  • Fax: 810-445-9971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2901017170
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number StateMI

VIII. Authorized Official

Name: MS. TRESHA KAYE YORTON
Title or Position: OFFICE MANAGER
Credential:
Phone: 810-445-9970