Provider Demographics
NPI:1316110778
Name:UPPER MICHIGAN ORAL & MAXILLOFACIAL SURGERY PC
Entity type:Organization
Organization Name:UPPER MICHIGAN ORAL & MAXILLOFACIAL SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:STANCHINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-228-7173
Mailing Address - Street 1:1250 WILSON ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-4454
Mailing Address - Country:US
Mailing Address - Phone:906-228-7173
Mailing Address - Fax:906-228-2916
Practice Address - Street 1:1250 WILSON ST
Practice Address - Street 2:SUITE 101
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-4454
Practice Address - Country:US
Practice Address - Phone:906-228-7173
Practice Address - Fax:906-228-2916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-08
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJ141451223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI124726184Medicaid