MEDICARE: ORAL SURGERY P.L.L.C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	2901019237	MI

General Provider Information

NPI Number	:	1295133460
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORAL SURGERY P.L.L.C

Provider Business Mailing Address
First Line	:	51745 VAN DYKE AVE
Second Line	:
City	:	SHELBY TOWNSHIP
State	:	MI
Zip	:	48316-4451
Country	:	US
Telephone Number	:	586-323-1600
Fax Number	:	586-323-1644

Provider Business Practice Location Address
First Line	:	51745 VAN DYKE AVE
Second Line	:
City	:	SHELBY TOWNSHIP
State	:	MI
Zip	:	48316-4451
Country	:	US
Telephone Number	:	586-323-1600
Fax Number	:	586-323-1644

Authorized Official
Title or Position	:	TX COORDINATOR
Name	:	MRS. AMY PHIPPS
Credential	:
Telephone Number	:	586-323-1600

Provider Enumeration Date	:	12/19/2014
Last Update Date	:	12/19/2014

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