Healthcare Provider Details

I. General information

NPI: 1811066129
Provider Name (Legal Business Name): SUMMIT ORAL & MAXILLOFACIAL SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 09/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29427 RYAN RD
WARREN MI
48092-2203
US

IV. Provider business mailing address

29425 RYAN RD
WARREN MI
48092-2203
US

V. Phone/Fax

Practice location:
  • Phone: 586-755-9340
  • Fax: 586-755-9341
Mailing address:
  • Phone: 586-755-9340
  • Fax: 586-755-9341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MS. JANE M WINDISCH
Title or Position: BILLING SPECIALIST
Credential:
Phone: 586-755-9340