# GREAT LAKES JAW SURGERY, PC

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

## Provider details

- **NPI number:** 1326291816
- **Authorized official:** DR. ROBERT JOHN ROSEMA D.D.S (OWNER/ ORAL SURGEON)
- **Authorized official phone:** (616) 281-2370

## Contact information

- **Practice address:** 2017 EASTCASTLE DR SE, SUITE C, GRAND RAPIDS, MI 49508-8872
- **Practice address phone:** (616) 281-2370
- **Practice address fax:** (616) 281-2801
- **Mailing address:** 2017 EASTCASTLE DR SE, SUITE C, GRAND RAPIDS, MI 49508-8872
- **Mailing address phone:** (616) 281-2370
- **Mailing address fax:** (616) 281-2801

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223S0112X | Oral and Maxillofacial Surgery (Dentist) | 2901011345 | MI | Yes |

## Other

- **Enumeration date:** 10/28/2008
- **Last updated:** 07/28/2020