Renaissance Oral Surgery PC

Primary specialty

Oral and Maxillofacial Surgery (Dentist)Taxonomy code 1223S0112X

Legal business name

RENAISSANCE ORAL SURGERY PC

Practice address

20805 E 12 Mile Rd
Ste 110
Roseville, MI 48066

Phone

(586) 778-2100

Fax

(586) 778-2422

NPI assigned

Sep 21, 2007

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Henry Bryan, DDSNPI 1992739379

Title

President

Phone

(586) 778-2100

Specialties & licenses 3

Addresses

Other identifiers 6

Medicare fee-for-service enrollment

Enrolled in MI

Enrollment records 1

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Henry Gasson Bryan, D.D.S.

  • Oral & Maxillofacial Surgery (D.M.D.)
  • Roseville, MI
  • NPI 1992739379

  Oral and Maxillofacial Surgery

  Medicare reassignment NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1190332800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1380585600000",
    "number": "1235325499",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "20805 E 12 MILE RD",
            "address_2": "STE 110",
            "city": "ROSEVILLE",
            "state": "MI",
            "postal_code": "48066",
            "telephone_number": "586-778-2100",
            "fax_number": "586-778-2422"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "20805 E 12 MILE RD",
            "address_2": "STE 110",
            "city": "ROSEVILLE",
            "state": "MI",
            "postal_code": "48066",
            "telephone_number": "586-778-2100",
            "fax_number": "586-778-2422"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "RENAISSANCE ORAL SURGERY PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-09-21",
        "last_updated": "2013-10-01",
        "status": "A",
        "authorized_official_last_name": "BRYAN",
        "authorized_official_first_name": "HENRY",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "586-778-2100",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "1223S0112X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "204E00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Oral & Maxillofacial Surgery",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2082S0099X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Plastic Surgery, Plastic Surgery Within the Head and Neck",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BC/BS MEDICARE ADVANTAGE",
            "identifier": "975506164",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "HAP",
            "identifier": "U33701",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "GOLDEN DENTAL",
            "identifier": "2856",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CARE CHOICES",
            "identifier": "128744",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BC/BS OF MI",
            "identifier": "975506164",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PROVIDER",
            "identifier": "P00230001",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Kaylee Marie Rayburn, OT
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• Oral and Maxillofacial Surgery (Dentist) in Roseville, MI
• Providers in Roseville, MI by specialty
• Oral and Maxillofacial Surgery (Dentist) in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 1, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.