Healthcare Provider Details

I. General information

NPI: 1609916667
Provider Name (Legal Business Name): NORTH COAST ORAL & MAXILLOFACIAL SURGERY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 02/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 W. STRUB RD. NOMS PROFESSIONAL BLDG. #1
SANDUSKY OH
44870
US

IV. Provider business mailing address

2500 W. STRUB RD. NOMS PROFESSIONAL BLDG. #1
SANDUSKY OH
44870
US

V. Phone/Fax

Practice location:
  • Phone: 419-627-8131
  • Fax: 419-621-1773
Mailing address:
  • Phone: 419-627-8131
  • Fax: 419-621-1773

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: TERENCE PATRICK KELLY
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 419-627-8131