Healthcare Provider Details

I. General information

NPI: 1831264324
Provider Name (Legal Business Name): ORAL & MAXILLOFACIAL SURGERY ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 08/18/2025
Certification Date: 08/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7845 CARNEGIE BLVD
FORT WAYNE IN
46804
US

IV. Provider business mailing address

7845 CARNEGIE BLVD
FORT WAYNE IN
46804-5792
US

V. Phone/Fax

Practice location:
  • Phone: 260-969-4105
  • Fax: 260-969-4118
Mailing address:
  • Phone: 260-969-4105
  • Fax: 260-969-4118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: CELESTE C SHOLL
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 260-969-4113