Healthcare Provider Details

I. General information

NPI: 1013171594
Provider Name (Legal Business Name): CARMEL ORAL & MAXILLOFACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2008
Last Update Date: 07/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13590B N MERIDIAN ST SUITE 105
CARMEL IN
46032-1456
US

IV. Provider business mailing address

13590B N MERIDIAN ST SUITE 105
CARMEL IN
46032-1406
US

V. Phone/Fax

Practice location:
  • Phone: 317-844-7626
  • Fax: 317-844-3804
Mailing address:
  • Phone: 317-844-7626
  • Fax: 317-844-3804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number12009721A
License Number StateIN

VIII. Authorized Official

Name: STANLEY C. JACHIMOWICZ
Title or Position: PRESIDENT
Credential: DDS
Phone: 317-844-7626