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General NPI Number Information
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NPI Number | 1962929240
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Entity Type | Organization
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Legal Business Name | MAXILLOFACIAL SURGERY INNOVATIVE SERVICES
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Dates
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Enumeration Date | 08/28/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 1284 SOM CENTER RD STE 219
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City | MAYFIELD HEIGHTS
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State | OH
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Zip | 44124-2048
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Country | US
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Telephone | 888-774-7773
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Fax | 888-774-7970
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Provider Business Mailing Address
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Address Line | 1284 SOM CENTER RD STE 219
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City | MAYFIELD HEIGHTS
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State | OH
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Zip | 44124-2048
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Country | US
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Telephone | 888-774-7773
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Fax | 888-774-7970
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Authorized Official
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Title or Position | CREDENTIALING DIRECTOR
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Name | MICHELLE ANN HANCOCK
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Credential | MS/P, MBA/HCM
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Telephone | 515-321-6451
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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