Healthcare Provider Details

I. General information

NPI: 1932540366
Provider Name (Legal Business Name): NORTHVILLE ORAL & MAXIOLLOFACIAL SURGERY PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2013
Last Update Date: 07/15/2013
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
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 Number17024
License Number StateMI

VIII. Authorized Official

Name: DR. ROBERT C JOHN
Title or Position: SURGEON
Credential: D.D.S., M. D.
Phone: 248-969-9500