Healthcare Provider Details

I. General information

NPI: 1245253111
Provider Name (Legal Business Name): PLYMOUTH ORAL & FACIAL SURGERY, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 03/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9416 S MAIN ST SUITE 211
PLYMOUTH MI
48170-4157
US

IV. Provider business mailing address

9416 S MAIN ST SUITE 211
PLYMOUTH MI
48170-4157
US

V. Phone/Fax

Practice location:
  • Phone: 734-455-0710
  • Fax: 734-455-4433
Mailing address:
  • Phone: 734-455-0710
  • Fax: 734-455-4433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2901017635
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2901012852
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2901011993
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2901014383
License Number StateMI

VIII. Authorized Official

Name: DR. DAVID H STURTZ
Title or Position: SENIOR PARTNER
Credential: D.D.S.
Phone: 734-455-0710