Healthcare Provider Details

I. General information

NPI: 1881696847
Provider Name (Legal Business Name): ORAL SURGERY OFFICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2204 SCOTT ST
LAFAYETTE IN
47904-2933
US

IV. Provider business mailing address

2204 SCOTT ST
LAFAYETTE IN
47904-2933
US

V. Phone/Fax

Practice location:
  • Phone: 765-447-0525
  • Fax: 765-447-5815
Mailing address:
  • Phone: 765-447-0525
  • Fax: 765-447-5815

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. DAVID BRIAN COATES
Title or Position: CO-OWNER
Credential: D.D.S.
Phone: 765-447-0525