Healthcare Provider Details

I. General information

NPI: 1881887065
Provider Name (Legal Business Name): EDISON LAKES ORAL SURGERY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2007
Last Update Date: 05/06/2024
Certification Date: 05/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3367 DOUGLAS RD
SOUTH BEND IN
46635-1779
US

IV. Provider business mailing address

3367 DOUGLAS RD
SOUTH BEND IN
46635-1779
US

V. Phone/Fax

Practice location:
  • Phone: 574-272-8823
  • Fax: 574-277-1837
Mailing address:
  • Phone: 574-272-8823
  • Fax: 574-277-1837

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 Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number12010802A
License Number StateIN

VIII. Authorized Official

Name: DR. EDWARD CHARLES COLLINS III
Title or Position: OWNER
Credential: DDS, MS
Phone: 574-272-8823