Healthcare Provider Details

I. General information

NPI: 1073855193
Provider Name (Legal Business Name): BUCKEYE ORAL & MAXILLOFACIAL SURGEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2013
Last Update Date: 03/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 POLARIS PARKWAY SUITE 110
WESTERVILLE OH
43082-0000
US

IV. Provider business mailing address

PO BOX 2443
WESTERVILLE OH
43086-2443
US

V. Phone/Fax

Practice location:
  • Phone: 614-794-9700
  • Fax:
Mailing address:
  • Phone: 614-794-9700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number30022456
License Number StateOH

VIII. Authorized Official

Name: DR. JACK B MCEWAN
Title or Position: OWNER
Credential: DDS
Phone: 614-794-9700