Healthcare Provider Details

I. General information

NPI: 1932999877
Provider Name (Legal Business Name): INDIANA ORAL AND FACIAL SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2025
Last Update Date: 05/12/2025
Certification Date: 05/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5120 CHARLESTOWN RD STE 1
NEW ALBANY IN
47150-9497
US

IV. Provider business mailing address

3700 INGLESIDE BLVD
LADSON SC
29456-4141
US

V. Phone/Fax

Practice location:
  • Phone: 812-944-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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: JACKIE HOLLOWAY
Title or Position: DIRECTOR OF RCM
Credential:
Phone: 854-200-7970