Healthcare Provider Details

I. General information

NPI: 1598772626
Provider Name (Legal Business Name): ORAL & MAXILLOFACIAL SURGERY ASSOCIATES OF WESTERN MICHIGAN PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 04/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2140 LAKE MICHIGAN DR NW
GRAND RAPIDS MI
49504-4785
US

IV. Provider business mailing address

2140 LAKE MICHIGAN DR NW
GRAND RAPIDS MI
49504-4785
US

V. Phone/Fax

Practice location:
  • Phone: 616-791-9600
  • Fax: 616-791-9603
Mailing address:
  • Phone: 616-791-9600
  • Fax: 616-791-9603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: J MARK DOMIN
Title or Position: MEMBER
Credential: DDS
Phone: 616-791-9600