Provider Demographics
NPI:1902993819
Name:GREAT LAKES ORAL SURGERY AND IMPLANTS, P.C.
Entity type:Organization
Organization Name:GREAT LAKES ORAL SURGERY AND IMPLANTS, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING & BILLING
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:A
Authorized Official - Last Name:KERN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-424-0705
Mailing Address - Street 1:5417 GATEWAY CENTRE BLVD.
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-3980
Mailing Address - Country:US
Mailing Address - Phone:810-424-0705
Mailing Address - Fax:810-424-0750
Practice Address - Street 1:5417 GATEWAY CTR
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-3980
Practice Address - Country:US
Practice Address - Phone:810-424-0705
Practice Address - Fax:810-424-0750
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREAT LAKES ORAL SURGERY AND IMPLANTS, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-10
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2594587Medicaid
MI9752562480OtherBLUE CROSS BLUE SHIELD
MI4045904Medicaid
MI975256759OtherBLUE CROSS BLUE SHIELD
MI4417670Medicaid
MI195256547OtherBLUE CROSS BLUE SHIELD
U18504Medicare UPIN
MIOP30330Medicare UPIN
T82821Medicare UPIN
MI4045904Medicaid