MEDICARE: EAST CENTRAL INDIANA ORAL AND MAXILLOFACIAL SURGERY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QS0112X	Oral and Maxillofacial Surgery Clinic/Center	12010966A	IN
2	261QS0112X	Oral and Maxillofacial Surgery Clinic/Center	12008702A	IN

General Provider Information

NPI Number	:	1720330004
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST CENTRAL INDIANA ORAL AND MAXILLOFACIAL SURGERY, LLC

Provider Business Mailing Address
First Line	:	3895 N WHEELING AVE
Second Line	:
City	:	MUNCIE
State	:	IN
Zip	:	47304-1776
Country	:	US
Telephone Number	:	765-281-1131
Fax Number	:

Provider Business Practice Location Address
First Line	:	3895 N WHEELING AVE
Second Line	:
City	:	MUNCIE
State	:	IN
Zip	:	47304-1776
Country	:	US
Telephone Number	:	765-281-1131
Fax Number	:

Authorized Official
Title or Position	:	PRACTICE CO-OWNER
Name	:	DR. HARRY PAPADOPOULOS
Credential	:	DDS, MD
Telephone Number	:	765-281-1131

Provider Enumeration Date	:	10/10/2012
Last Update Date	:	10/10/2012

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