Healthcare Provider Details

I. General information

NPI: 1134100902
Provider Name (Legal Business Name): NORTHWEST ORAL SURGEONS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 08/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601A W US HWY 30
SCHERERVILLE IN
46375-2656
US

IV. Provider business mailing address

601A W US HWY 30
SCHERERVILLE IN
46375-2656
US

V. Phone/Fax

Practice location:
  • Phone: 219-322-0501
  • Fax: 219-322-0577
Mailing address:
  • Phone: 219-322-0501
  • Fax: 219-322-0577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number54000342A
License Number StateIN

VIII. Authorized Official

Name: MR. PAUL L WOLF
Title or Position: OFFICER
Credential: DDS
Phone: 219-322-0501