Lake Michigan Oral & Maxillofacial Surgery PLLC

Primary specialty

Oral and Maxillofacial Surgery (Dentist)Taxonomy code 1223S0112X

License

2901018748 Issued in MI

Legal business name

LAKE MICHIGAN ORAL & MAXILLOFACIAL SURGERY PLLC

Practice address

3950 Hollywood Rd
290
Saint Joseph, MI 49085-9151

Phone

(405) 848-7974

Fax

(405) 848-0033

NPI assigned

Aug 5, 2010

Organization subpart

No

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

Authorized official

Name

Lisa Keough

Title

Credentialing Rep

Phone

(405) 848-7974

Specialties & licenses 1

Addresses

Locations

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

{
    "created_epoch": "1280966400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1280966400000",
    "number": "1245544824",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3000 UNITED FOUNDERS BLVD",
            "address_2": "237",
            "city": "OKLAHOMA CITY",
            "state": "OK",
            "postal_code": "731123958",
            "telephone_number": "405-848-7974",
            "fax_number": "405-848-0033"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3950 HOLLYWOOD RD",
            "address_2": "290",
            "city": "SAINT JOSEPH",
            "state": "MI",
            "postal_code": "490859151",
            "telephone_number": "405-848-7974",
            "fax_number": "405-848-0033"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKE MICHIGAN ORAL & MAXILLOFACIAL SURGERY PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-08-05",
        "last_updated": "2010-08-05",
        "status": "A",
        "authorized_official_last_name": "KEOUGH",
        "authorized_official_first_name": "LISA",
        "authorized_official_title_or_position": "CREDENTIALING REP",
        "authorized_official_telephone_number": "405-848-7974"
    },
    "taxonomies": [
        {
            "code": "1223S0112X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "MI",
            "license": "2901018748",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Lake House Counseling PLLC
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• Lake Michigan Neurolgical Surgery
• Lake Michigan Sinus & Sleep Apnea Center, PLLC
• Lakeland Anesthesia, PC
• Lakeland Community Hospital Watervliet
• Lakeland Health Services
• Lakeland Hospital at Niles and St Joseph, Inc

• Oral and Maxillofacial Surgery (Dentist) in Saint Joseph, MI
• Providers in Saint Joseph, 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 Aug 5, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.