Healthcare Provider Details

I. General information

NPI: 1245692425
Provider Name (Legal Business Name): CENTERPOINTE ORAL AND MAXILLOFACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2016
Last Update Date: 03/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18530 MACK AVE SUITE 192
GROSSE POINTE FARMS MI
48236-3254
US

IV. Provider business mailing address

18530 MACK AVE SUITE 192
GROSSE POINTE FARMS MI
48236-3254
US

V. Phone/Fax

Practice location:
  • Phone: 231-487-9000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberL839484
License Number StateMI

VIII. Authorized Official

Name: DR. BROCK C MCKINLEY
Title or Position: PRESIDENT / CEO
Credential: DDS
Phone: 231-487-9000