Healthcare Provider Details

I. General information

NPI: 1629134515
Provider Name (Legal Business Name): COLUMBUS ORAL & MAXILLOFACIAL SURGERY PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 04/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2350 NORTHPARK
COLUMBUS IN
47203-4466
US

IV. Provider business mailing address

2350 NORTHPARK
COLUMBUS IN
47203-4466
US

V. Phone/Fax

Practice location:
  • Phone: 812-372-7312
  • Fax: 812-378-9451
Mailing address:
  • Phone: 812-372-7312
  • Fax: 812-378-9451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number54000102A
License Number StateIN

VIII. Authorized Official

Name: BARBARA KAISER
Title or Position: OFFICE MANAGER
Credential:
Phone: 812-372-7312