Healthcare Provider Details

I. General information

NPI: 1174892772
Provider Name (Legal Business Name): RANDY L BISPING DDS MS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2011
Last Update Date: 03/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3579 HENRY ST SUITE 140
NORTON SHORES MI
49441-6720
US

IV. Provider business mailing address

3579 HENRY ST SUITE 140
NORTON SHORES MI
49441-6720
US

V. Phone/Fax

Practice location:
  • Phone: 231-739-1215
  • Fax: 231-737-2347
Mailing address:
  • Phone: 231-739-1215
  • Fax: 231-737-2347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2901014916
License Number StateMI

VIII. Authorized Official

Name: DR. RANDY LEE BISPING
Title or Position: ORAL SURGEON
Credential: D.D.S.M.S.P.C.
Phone: 231-739-1215