Healthcare Provider Details

I. General information

NPI: 1942468186
Provider Name (Legal Business Name): MID MICHIGAN ORAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2008
Last Update Date: 06/25/2024
Certification Date: 06/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 CHARLEVOIX DR
GRAND LEDGE MI
48837-2417
US

IV. Provider business mailing address

1040 CHARLEVOIX DR
GRAND LEDGE MI
48837-2417
US

V. Phone/Fax

Practice location:
  • Phone: 517-627-4088
  • Fax: 517-627-3908
Mailing address:
  • Phone: 517-627-4088
  • Fax: 517-627-3908

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: DR. MARK E BECKMAN
Title or Position: ORAL SURGEON / OWNER
Credential: DDS, MS
Phone: 517-627-4088