Provider Demographics
NPI:1861729261
Name:NORTHVILLE ORAL &FACIAL SURGERY CENTER
Entity type:Organization
Organization Name:NORTHVILLE ORAL &FACIAL SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:TIMOTHY
Authorized Official - Last Name:BLISS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:248-344-4224
Mailing Address - Street 1:430 N CENTER ST
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-1224
Mailing Address - Country:US
Mailing Address - Phone:248-344-4224
Mailing Address - Fax:248-344-4883
Practice Address - Street 1:430 N CENTER ST
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167-1224
Practice Address - Country:US
Practice Address - Phone:248-344-4224
Practice Address - Fax:248-344-4883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-06
Last Update Date:2009-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MID1667201223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty