Healthcare Provider Details

I. General information

NPI: 1619964715
Provider Name (Legal Business Name): MIDLAND ORAL & MAXILLOFACIAL SURGERY P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 02/17/2020
Certification Date: 02/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6112 MERLIN CT
MIDLAND MI
48640
US

IV. Provider business mailing address

6112 MERLIN CT
MIDLAND MI
48640-7358
US

V. Phone/Fax

Practice location:
  • Phone: 989-839-9979
  • Fax: 989-839-9553
Mailing address:
  • Phone: 989-839-9979
  • Fax: 989-839-9553

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: SHIANNE BOWERS
Title or Position: FINANCIAL DEPT
Credential:
Phone: 989-839-9979