Healthcare Provider Details

I. General information

NPI: 1467506188
Provider Name (Legal Business Name): ORAL SURGERY GROUP OF EVANSVILLE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 W VIRGINIA ST
EVANSVILLE IN
47710-1614
US

IV. Provider business mailing address

550 W VIRGINIA ST
EVANSVILLE IN
47710-1614
US

V. Phone/Fax

Practice location:
  • Phone: 812-425-5194
  • Fax: 812-426-9984
Mailing address:
  • Phone: 812-425-5194
  • Fax: 812-426-9984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number54000277A
License Number StateIN

VIII. Authorized Official

Name: MS. KAREN L KELLAMS
Title or Position: PRACTICE MANAGER
Credential:
Phone: 812-425-5194