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General NPI Number Information
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NPI Number | 1235325499
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Entity Type | Organization
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Legal Business Name | RENAISSANCE ORAL SURGERY PC
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Dates
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Enumeration Date | 09/21/2007
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Last Update Date | 10/01/2013
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Provider Practice Location Address
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Address Line | 20805 E 12 MILE RD STE 110
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City | ROSEVILLE
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State | MI
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Zip | 48066
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Country | US
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Telephone | 586-778-2100
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Fax | 586-778-2422
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Provider Business Mailing Address
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Address Line | 20805 E 12 MILE RD STE 110
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City | ROSEVILLE
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State | MI
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Zip | 48066
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Country | US
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Telephone | 586-778-2100
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Fax | 586-778-2422
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. HENRY BRYAN
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Credential | DDS
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Telephone | 586-778-2100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 204E00000X
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Taxonomy Name | Oral & Maxillofacial Surgery (D.M.D.)
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2082S0099X
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Taxonomy Name | Plastic Surgery Within the Head and Neck (Plastic Surgery) Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number |
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License Number State |
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