Healthcare Provider Details

I. General information

NPI: 1861729261
Provider Name (Legal Business Name): NORTHVILLE ORAL &FACIAL SURGERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2009
Last Update Date: 11/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 N CENTER ST
NORTHVILLE MI
48167-1224
US

IV. Provider business mailing address

430 N CENTER ST
NORTHVILLE MI
48167-1224
US

V. Phone/Fax

Practice location:
  • Phone: 248-344-4224
  • Fax: 248-344-4883
Mailing address:
  • Phone: 248-344-4224
  • Fax: 248-344-4883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD166720
License Number StateMI

VIII. Authorized Official

Name: DR. PETER TIMOTHY BLISS
Title or Position: PRESIDENT
Credential: DMD
Phone: 248-344-4224