Healthcare Provider Details

I. General information

NPI: 1376181347
Provider Name (Legal Business Name): ORAL SURGERY OF INDIANA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2019
Last Update Date: 12/20/2019
Certification Date: 12/20/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 S TILLOTSON AVE
MUNCIE IN
47304-4448
US

IV. Provider business mailing address

620 S TILLOTSON AVE
MUNCIE IN
47304-4448
US

V. Phone/Fax

Practice location:
  • Phone: 770-692-1000
  • Fax:
Mailing address:
  • Phone: 770-692-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TAMONIA LEONARD
Title or Position: CREDENTAILING SPECIALIST
Credential:
Phone: 678-244-4844