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General NPI Number Information
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NPI Number | 1316110778
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Entity Type | Organization
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Legal Business Name | UPPER MICHIGAN ORAL & MAXILLOFACIAL SURGERY PC
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Dates
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Enumeration Date | 04/08/2008
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Last Update Date | 11/01/2016
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Provider Practice Location Address
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Address Line | 1250 WILSON ST SUITE 101
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City | MARQUETTE
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State | MI
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Zip | 49855-4454
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Country | US
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Telephone | 906-228-7173
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Fax | 906-228-2916
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Provider Business Mailing Address
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Address Line | 1250 WILSON ST SUITE 101
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City | MARQUETTE
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State | MI
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Zip | 49855-4454
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Country | US
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Telephone | 906-228-7173
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Fax | 906-228-2916
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Authorized Official
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Title or Position | PRESIDENT
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Name | RICHARD STANCHINA
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Credential |
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Telephone | 906-228-7173
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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 | J14145
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License Number State | MI
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