Provider Demographics
NPI:1427457191
Name:KEYSTONE ORAL AND MAXILLOFACIAL SURGERY PC
Entity type:Organization
Organization Name:KEYSTONE ORAL AND MAXILLOFACIAL SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:E
Authorized Official - Last Name:KASPER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:586-914-0093
Mailing Address - Street 1:36975 UTICA RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48036-1685
Mailing Address - Country:US
Mailing Address - Phone:586-226-2801
Mailing Address - Fax:586-226-1519
Practice Address - Street 1:36975 UTICA RD
Practice Address - Street 2:SUITE 106
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48036-1685
Practice Address - Country:US
Practice Address - Phone:586-226-2801
Practice Address - Fax:586-226-1519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-19
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010173901223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0E04308OtherBLUE CROSS BLUE SHIELD
MIMI7945Medicare PIN