Healthcare Provider Details

I. General information

NPI: 1053458604
Provider Name (Legal Business Name): WEST SHORE ORAL & MAXILLOFACIAL SURGERY ASSOCIATES, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 06/12/2020
Certification Date: 06/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5957 HARVEY ST
NORTON SHORES MI
49444-9737
US

IV. Provider business mailing address

5957 HARVEY ST STE 200
NORTON SHORES MI
49444-6735
US

V. Phone/Fax

Practice location:
  • Phone: 231-733-1571
  • Fax: 231-733-5228
Mailing address:
  • Phone: 231-733-1571
  • Fax: 231-733-5228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberB7708N
License Number StateMI

VIII. Authorized Official

Name: MARK T. BURYE
Title or Position: OWNER
Credential: DDS
Phone: 231-733-1571