Organization
ORAL & MAXILLOFACIAL SURGERY ASSOCIATES OF WESTERN MICHIGAN PLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
J MARK DOMIN DDS (MEMBER)
(616) 791-9600
Entity
Organization
Contact information
Practice address
2140 LAKE MICHIGAN DR NW, GRAND RAPIDS, MI 49504-4785
(616) 791-9600
(616) 791-9603
Mailing address
2140 LAKE MICHIGAN DR NW, GRAND RAPIDS, MI 49504-4785
(616) 791-9600
(616) 791-9603
Taxonomy
Speciality
Code
Description
License number
State
204E00000X
Oral & Maxillofacial Surgery (D.M.D.)
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0N13750
MEDICARE GROUP NUMBER
MI
01
—
970D111530
BCBSM BCN/CHOICE
—
01
—
CC0861
MEDICARE RAILROAD
—
Enumeration date
08/02/2006
Last updated
04/12/2010
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