Healthcare Provider Details

I. General information

NPI: 1831377712
Provider Name (Legal Business Name): ORAL SURGERY GROUP OF SOUTHERN INDIANA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2008
Last Update Date: 05/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2441 STATE ST
NEW ALBANY IN
47150-4962
US

IV. Provider business mailing address

PO BOX 437169
LOUISVILLE KY
40253-7169
US

V. Phone/Fax

Practice location:
  • Phone: 812-944-7200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: STEVE JAMES
Title or Position: COO
Credential:
Phone: 502-254-8504