=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710127188
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OAKLAND ORAL SURGERY ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/25/2009
-----------------------------------------------------
Last Update Date | 02/25/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 31646 SCHOOLCRAFT RD
-----------------------------------------------------
City | LIVONIA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48150-1819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-427-3366
-----------------------------------------------------
Fax | 734-427-0407
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 31646 SCHOOLCRAFT RD
-----------------------------------------------------
City | LIVONIA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48150-1819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-427-3366
-----------------------------------------------------
Fax | 734-427-0407
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ORAL AND MAXILLOFACIAL SURGEON
-----------------------------------------------------
Name | DR. JACK F MOORES
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 734-427-3366
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | JM16423
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------