Healthcare Provider Details

I. General information

NPI: 1649347832
Provider Name (Legal Business Name): FORT WAYNE ORAL MAXILLOFACIAL SURGERY & IMPLANT CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 10/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 E DUPONT RD SUITE #C
FORT WAYNE IN
46825-1546
US

IV. Provider business mailing address

2121 E DUPONT RD SUITE #C
FORT WAYNE IN
46825-1546
US

V. Phone/Fax

Practice location:
  • Phone: 260-490-2013
  • Fax: 260-490-1081
Mailing address:
  • Phone: 260-490-2013
  • Fax: 260-490-1081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. MULOKOZI K. LUGAKINGIRA
Title or Position: PRESIDENT
Credential: DMD, MS, DDS
Phone: 260-490-2013