Healthcare Provider Details

I. General information

NPI: 1235325499
Provider Name (Legal Business Name): RENAISSANCE ORAL SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2007
Last Update Date: 10/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20805 E 12 MILE RD STE 110
ROSEVILLE MI
48066
US

IV. Provider business mailing address

20805 E 12 MILE RD STE 110
ROSEVILLE MI
48066
US

V. Phone/Fax

Practice location:
  • Phone: 586-778-2100
  • Fax: 586-778-2422
Mailing address:
  • Phone: 586-778-2100
  • Fax: 586-778-2422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: MR. HENRY BRYAN
Title or Position: PRESIDENT
Credential: DDS
Phone: 586-778-2100