Healthcare Provider Details

I. General information

NPI: 1942426341
Provider Name (Legal Business Name): EAST INDIANAPOLIS ORAL AND MAXILLOFACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 N SHORTRIDGE RD
INDIANAPOLIS IN
46219-4908
US

IV. Provider business mailing address

125 N SHORTRIDGE RD
INDIANAPOLIS IN
46219-4908
US

V. Phone/Fax

Practice location:
  • Phone: 317-353-1320
  • Fax: 317-359-5243
Mailing address:
  • Phone: 317-353-1320
  • Fax: 317-359-5243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. MATTHEW C MOLL
Title or Position: OWNER
Credential: DDS
Phone: 317-353-1320