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General NPI Number Information
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NPI Number | 1295375137
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Entity Type | Organization
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Legal Business Name | ORAL & MAXILLOFACIAL SURGERY OF GREATER GRAND RAPIDS LLC
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Dates
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Enumeration Date | 01/08/2020
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Last Update Date | 01/08/2020
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Provider Practice Location Address
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Address Line | 9021 N RODGERS CT SE STE A
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City | CALEDONIA
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State | MI
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Zip | 49316-7650
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Country | US
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Telephone | 616-891-1700
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Fax | 616-891-9306
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Provider Business Mailing Address
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Address Line | 9021 N RODGERS CT SE STE A
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City | CALEDONIA
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State | MI
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Zip | 49316-7650
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Country | US
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Telephone | 616-891-1700
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Fax | 616-891-9306
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Authorized Official
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Title or Position | ORAL SURGEON
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Name | BRADLEY G VANHOOSE GARRETT VANHOOSE
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Credential | DDS MS
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Telephone | 616-891-1700
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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 |
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License Number State |
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