Healthcare Provider Details

I. General information

NPI: 1154483014
Provider Name (Legal Business Name): NORTHERN MICHIGAN ORAL AND MAXILLOFACIAL SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

322 BAY ST
PETOSKEY MI
49770-2489
US

IV. Provider business mailing address

322 BAY ST
PETOSKEY MI
49770-2489
US

V. Phone/Fax

Practice location:
  • Phone: 231-347-1601
  • Fax:
Mailing address:
  • Phone: 231-347-1601
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2901013255
License Number StateMI

VIII. Authorized Official

Name: DR. JAMES OSETEK
Title or Position: OWNER
Credential: DMD
Phone: 231-347-1601