Provider Demographics
NPI:1174892772
Name:RANDY L BISPING DDS MS PC
Entity type:Organization
Organization Name:RANDY L BISPING DDS MS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BISPING
Authorized Official - Suffix:
Authorized Official - Credentials:DDSMSPC
Authorized Official - Phone:231-739-1215
Mailing Address - Street 1:3579 HENRY ST
Mailing Address - Street 2:SUITE 140
Mailing Address - City:NORTON SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:49441-6720
Mailing Address - Country:US
Mailing Address - Phone:231-739-1215
Mailing Address - Fax:231-737-2347
Practice Address - Street 1:3579 HENRY ST
Practice Address - Street 2:SUITE 140
Practice Address - City:NORTON SHORES
Practice Address - State:MI
Practice Address - Zip Code:49441-6720
Practice Address - Country:US
Practice Address - Phone:231-739-1215
Practice Address - Fax:231-737-2347
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-28
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010149161223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI122658890Medicaid