Provider Demographics
NPI:1548283559
Name:ORAL AND MAXILLOFACIAL SURGERY SERVICES, PLC
Entity type:Organization
Organization Name:ORAL AND MAXILLOFACIAL SURGERY SERVICES, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:L
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:616-977-5000
Mailing Address - Street 1:4500 CASCADE RD SE
Mailing Address - Street 2:SUITE #208
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3665
Mailing Address - Country:US
Mailing Address - Phone:616-977-5000
Mailing Address - Fax:616-977-0020
Practice Address - Street 1:4500 CASCADE RD SE
Practice Address - Street 2:SUITE #208
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3665
Practice Address - Country:US
Practice Address - Phone:616-977-5000
Practice Address - Fax:616-977-0020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIKE0115531223P0106X, 1223S0112X, 1223X0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Multi-Specialty
Not Answered1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Not Answered1223X0008XDental ProvidersDentistOral and Maxillofacial RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIT82820Medicare UPIN
MI0P27850Medicare ID - Type Unspecified