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General NPI Number Information
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NPI Number | 1861122871
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Entity Type | Organization
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Legal Business Name | SOUTH SHORE OMS PC
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Dates
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Enumeration Date | 06/13/2022
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Last Update Date | 06/13/2022
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Provider Practice Location Address
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Address Line | 19249 ALLEN RD
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City | BROWNSTOWN TWP
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State | MI
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Zip | 48183-1189
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Country | US
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Telephone | 734-479-2990
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Fax | 734-479-2991
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Provider Business Mailing Address
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Address Line | 19249 ALLEN RD
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City | BROWNSTOWN TWP
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State | MI
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Zip | 48183-1189
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Country | US
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Telephone | 734-479-2990
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATIVE
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Name | KELLY DOHERTY
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Credential |
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Telephone | 734-479-2990
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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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