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General NPI Number Information
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NPI Number | 1114856226
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Entity Type | Organization
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Legal Business Name | BREAKWATER ORAL AND MAXILLOFACIAL SURGERY PLLC
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Dates
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Enumeration Date | 05/15/2026
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Last Update Date | 05/15/2026
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Provider Practice Location Address
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Address Line | 1000 W UNIVERSITY DR STE 207
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City | ROCHESTER
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State | MI
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Zip | 48307-1875
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Country | US
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Telephone | 402-805-4516
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Fax |
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Provider Business Mailing Address
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Address Line | 1000 W UNIVERSITY DR STE 207
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City | ROCHESTER
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State | MI
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Zip | 48307-1875
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING MANAGER
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Name | JENN HERITAGE
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Credential |
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Telephone | 402-805-4516
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number |
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License Number State |
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