Provider Demographics
NPI:1154800357
Name:MIDWEST IMPLANT SURGERY CENTER
Entity type:Organization
Organization Name:MIDWEST IMPLANT SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:MS
Authorized Official - First Name:BRANDYNN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-457-2299
Mailing Address - Street 1:2064 BALDWIN ST
Mailing Address - Street 2:
Mailing Address - City:JENISON
Mailing Address - State:MI
Mailing Address - Zip Code:49428-8773
Mailing Address - Country:US
Mailing Address - Phone:616-457-2299
Mailing Address - Fax:
Practice Address - Street 1:2064 BALDWIN ST
Practice Address - Street 2:
Practice Address - City:JENISON
Practice Address - State:MI
Practice Address - Zip Code:49428-8773
Practice Address - Country:US
Practice Address - Phone:616-457-2299
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIDWEST FAMILY DENTAL CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty