Healthcare Provider Details

I. General information

NPI: 1326291816
Provider Name (Legal Business Name): GREAT LAKES JAW SURGERY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2008
Last Update Date: 07/28/2020
Certification Date: 07/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2017 EASTCASTLE DR SE SUITE C
GRAND RAPIDS MI
49508-8872
US

IV. Provider business mailing address

2017 EASTCASTLE DR SE SUITE C
GRAND RAPIDS MI
49508-8872
US

V. Phone/Fax

Practice location:
  • Phone: 616-281-2370
  • Fax: 616-281-2801
Mailing address:
  • Phone: 616-281-2370
  • Fax: 616-281-2801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2901011345
License Number StateMI

VIII. Authorized Official

Name: DR. ROBERT JOHN ROSEMA
Title or Position: OWNER/ ORAL SURGEON
Credential: D.D.S
Phone: 616-281-2370