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General NPI Number Information
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NPI Number | 1629445986
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Entity Type | Organization
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Legal Business Name | WESTERN LAKE ERIE OMS, PC
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Dates
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Enumeration Date | 08/21/2015
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Last Update Date | 07/31/2019
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Provider Practice Location Address
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Address Line | 876 STEWART RD #3
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City | MONROE
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State | MI
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Zip | 48162-5345
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Country | US
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Telephone | 734-243-9160
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Fax | 734-243-6393
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Provider Business Mailing Address
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Address Line | 876 STEWART RD #3
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City | MONROE
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State | MI
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Zip | 48162-5345
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Country | US
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Telephone | 734-243-9160
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Fax | 734-243-6393
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Authorized Official
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Title or Position | PRACTICE ADMINISTRATOR
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Name | MRS. WENDY VORE
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Credential |
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Telephone | 734-243-9160
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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 | MI
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Taxonomy #2
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Taxonomy Code | 261QS0112X
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Taxonomy Name | Oral and Maxillofacial Surgery Clinic/Center
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License Number |
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License Number State |
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