Great Lakes Oral Surgery and Implants, P.C.

Primary specialty

Oral and Maxillofacial Surgery (Dentist)Taxonomy code 1223S0112X

Legal business name

GREAT LAKES ORAL SURGERY AND IMPLANTS, P.C.

Doing business as

Greater Michigan Oral Surgeons & Dental Implant Center

Practice address

5417 Gateway Ctr
Flint, MI 48507-3980

Phone

(810) 424-0705

Fax

(810) 424-0750

NPI assigned

Oct 10, 2006

Last updated

Aug 28, 2024By the provider in NPPES

Organization subpart

Yes

Parent organization

GREAT LAKES ORAL SURGERY AND IMPLANTS, P.C.As reported in NPPES

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

Authorized official

Name

Samantha A Kern

Title

Credentialing & Billing

Phone

(810) 424-0705

Specialties & licenses 1

Addresses

Other identifiers 6

Other names 2

• Greater Michigan Oral Surgeons & Dental Implant Center Doing business as
• Oral and Maxillofacial Surgery, P.C. Former legal business name

Medicare fee-for-service enrollment

Enrolled in MI

Enrollment records 1

Part of

Michael S Frey DDS

Locations

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Robert C. John, D.D.S., M.D.

  • Oral and Maxillofacial Surgery (Dentist)
  • Troy, MI
  • NPI 1598765604
  Medicare reassignment NPD
• Ahmad-Reza Noroozi, DDS

  • Oral and Maxillofacial Surgery (Dentist)
  • Owosso, MI
  • NPI 1467609719
  Medicare reassignment NPD
• Melvin J. Flamenbaum, D.M.D.

  • Oral and Maxillofacial Surgery (Dentist)
  • Flint, MI
  • NPI 1639266547
  NPD (past)

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

{
    "created_epoch": "1160438400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1724803200000",
    "number": "1902993819",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5417 GATEWAY CENTRE BLVD.",
            "city": "FLINT",
            "state": "MI",
            "postal_code": "485073980",
            "telephone_number": "810-424-0705",
            "fax_number": "810-424-0750"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5417 GATEWAY CTR",
            "city": "FLINT",
            "state": "MI",
            "postal_code": "485073980",
            "telephone_number": "810-424-0705",
            "fax_number": "810-424-0750"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GREAT LAKES ORAL SURGERY AND IMPLANTS, P.C.",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "GREAT LAKES ORAL SURGERY AND IMPLANTS, P.C.",
        "enumeration_date": "2006-10-10",
        "last_updated": "2024-08-28",
        "certification_date": "2024-08-28",
        "status": "A",
        "authorized_official_last_name": "KERN",
        "authorized_official_first_name": "SAMANTHA",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "CREDENTIALING & BILLING",
        "authorized_official_telephone_number": "810-424-0705"
    },
    "taxonomies": [
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "4045904",
            "state": "MI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "4417670",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "9752562480",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "975256759",
            "state": "MI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2594587",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "195256547",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Greater Michigan Oral Surgeons & Dental Implant Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Oral and Maxillofacial Surgery, P.C.",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

• Great Health Medical Mi PC
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• Great Lakes Dental Services PLLC
• Great Lakes Interventional Pain Management,PLLC
• Great Lakes Orthotics and Prosthetics (Great lakes O and P)
• Great Lakes Pain & Rehab, PC
• Great Lakes Recovery Mission
• Great Lakes Recovery Mission, LLC
• Great Lakes Recovery Mission, LLC

• Oral and Maxillofacial Surgery (Dentist) in Flint, MI
• Providers in Flint, 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 28, 2024; 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.