Healthcare Provider Details

I. General information

NPI: 1255411542
Provider Name (Legal Business Name): RICHMOND ORAL SURGERY ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

888 SIM HODGIN PKWY
RICHMOND IN
47374-1936
US

IV. Provider business mailing address

888 SIM HODGIN PKWY
RICHMOND IN
47374-1936
US

V. Phone/Fax

Practice location:
  • Phone: 765-966-7537
  • Fax: 765-966-0370
Mailing address:
  • Phone: 765-966-7537
  • Fax: 765-966-0370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number54000188A
License Number StateIN

VIII. Authorized Official

Name: J. ROBERT HALL
Title or Position: PRESIDENT/ORAL SURGEON
Credential: DDS
Phone: 765-966-7537