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General NPI Number Information
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NPI Number | 1245692425
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Entity Type | Organization
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Legal Business Name | CENTERPOINTE ORAL AND MAXILLOFACIAL SURGERY
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Dates
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Enumeration Date | 03/25/2016
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Last Update Date | 03/25/2016
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Provider Practice Location Address
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Address Line | 18530 MACK AVE SUITE 192
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City | GROSSE POINTE FARMS
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State | MI
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Zip | 48236-3254
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Country | US
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Telephone | 231-487-9000
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Fax |
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Provider Business Mailing Address
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Address Line | 18530 MACK AVE SUITE 192
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City | GROSSE POINTE FARMS
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State | MI
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Zip | 48236-3254
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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 | PRESIDENT / CEO
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Name | DR. BROCK C MCKINLEY
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Credential | DDS
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Telephone | 231-487-9000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | L839484
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License Number State | MI
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