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General NPI Number Information
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NPI Number | 1487375218
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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 | 09/09/2022
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Last Update Date | 08/01/2023
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Provider Practice Location Address
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Address Line | 6207 HARVEY ST STE A
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City | NORTON SHORES
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State | MI
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Zip | 49444-7861
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Country | US
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Telephone | 231-220-0500
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Fax | 231-220-0300
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Provider Business Mailing Address
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Address Line | 6207 HARVEY ST STE A
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City | NORTON SHORES
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State | MI
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Zip | 49444-7861
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Country | US
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Telephone | 231-220-0500
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Fax |
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Authorized Official
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Title or Position | INSURANCE COORDINATOR
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Name | ALEXIS FAIRFIELD
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Credential |
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Telephone | 231-220-0500
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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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