Healthcare Provider Details

I. General information

NPI: 1710366323
Provider Name (Legal Business Name): TRI-STATE ORAL SURGERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2015
Last Update Date: 05/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 BENTEE WES CT
EVANSVILLE IN
47715-4061
US

IV. Provider business mailing address

405 BENTEE WES CT
EVANSVILLE IN
47715-4061
US

V. Phone/Fax

Practice location:
  • Phone: 812-401-3500
  • Fax: 812-401-3600
Mailing address:
  • Phone: 812-401-3500
  • Fax: 812-401-3600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number12009501A
License Number StateIN

VIII. Authorized Official

Name: DR. MARK E. WOHLFORD
Title or Position: OWNER
Credential: DDS, PHD
Phone: 812-401-3500