Provider Demographics
NPI:1902551351
Name:THIRD COAST ORAL & MAXILLOFACIAL SURGERY
Entity Type:Organization
Organization Name:THIRD COAST ORAL & MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANNIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-583-7307
Mailing Address - Street 1:2119 64TH ST SW
Mailing Address - Street 2:
Mailing Address - City:BYRON CENTER
Mailing Address - State:MI
Mailing Address - Zip Code:49315-9409
Mailing Address - Country:US
Mailing Address - Phone:616-217-3632
Mailing Address - Fax:616-217-3634
Practice Address - Street 1:2119 64TH ST SW
Practice Address - Street 2:
Practice Address - City:BYRON CENTER
Practice Address - State:MI
Practice Address - Zip Code:49315-9409
Practice Address - Country:US
Practice Address - Phone:616-217-3632
Practice Address - Fax:616-217-3634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-15
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1811378508OtherNPPES
MI1811378508OtherNPI