=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831546407
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LONGHORN RANCH ORAL AND MAXILLOFACIAL SURGERY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2016
-----------------------------------------------------
Last Update Date | 10/14/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3610 CAPITAL AVE SW
-----------------------------------------------------
City | BATTLE CREEK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49015-9354
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-965-1339
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3610 CAPITAL AVE SW
-----------------------------------------------------
City | BATTLE CREEK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49015-9354
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-965-1339
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JONATHAN BONNET
-----------------------------------------------------
Credential | MD, DDS
-----------------------------------------------------
Telephone | 214-226-3980
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 2901020237
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------