Healthcare Provider Details

I. General information

NPI: 1174534515
Provider Name (Legal Business Name): FISHERS ORAL & MAXILLOFACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 10/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9126 TECHNOLOGY LN STE 300
FISHERS IN
46038-3064
US

IV. Provider business mailing address

9126 TECHNOLOGY LN STE 300
FISHERS IN
46038-3064
US

V. Phone/Fax

Practice location:
  • Phone: 317-849-3667
  • Fax: 317-849-3668
Mailing address:
  • Phone: 317-849-3667
  • Fax: 317-849-3668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number12007758
License Number StateIN

VIII. Authorized Official

Name: DR. MICHAEL D BENNETT
Title or Position: PRESIDENT SURGEON
Credential: DDS
Phone: 317-849-3667