# LAKE MICHIGAN ORAL & MAXILLOFACIAL SURGERY PLLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1245544824
- **Authorized official:** LISA KEOUGH (CREDENTIALING REP)
- **Authorized official phone:** (405) 848-7974

## Contact information

- **Practice address:** 3950 HOLLYWOOD RD, 290, SAINT JOSEPH, MI 49085-9151
- **Practice address phone:** (405) 848-7974
- **Practice address fax:** (405) 848-0033
- **Mailing address:** 3000 UNITED FOUNDERS BLVD, 237, OKLAHOMA CITY, OK 73112-3958
- **Mailing address phone:** (405) 848-7974
- **Mailing address fax:** (405) 848-0033

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223S0112X | Oral and Maxillofacial Surgery (Dentist) | 2901018748 | MI | Yes |

## Other

- **Enumeration date:** 08/05/2010
- **Last updated:** 08/05/2010