Healthcare Provider Details

I. General information

NPI: 1043309719
Provider Name (Legal Business Name): COLLEGE PARK ORAL & MAXILLOFACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3677 W 86TH STREET
INDIANAPOLIS IN
46268-1902
US

IV. Provider business mailing address

3677 W 86TH STREET
INDIANAPOLIS IN
56268-1902
US

V. Phone/Fax

Practice location:
  • Phone: 317-872-7777
  • Fax: 317-872-3174
Mailing address:
  • Phone: 317-872-7777
  • Fax:

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. J HAROLD SMITH II
Title or Position: PRESIDENT
Credential: DDS
Phone: 317-872-7777