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General NPI Number Information
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NPI Number | 1073855193
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Entity Type | Organization
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Legal Business Name | BUCKEYE ORAL & MAXILLOFACIAL SURGEY
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Dates
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Enumeration Date | 03/27/2013
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Last Update Date | 03/27/2013
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Provider Practice Location Address
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Address Line | 110 POLARIS PARKWAY SUITE 110
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City | WESTERVILLE
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State | OH
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Zip | 43082-0000
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Country | US
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Telephone | 614-794-9700
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 2443
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City | WESTERVILLE
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State | OH
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Zip | 43086-2443
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Country | US
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Telephone | 614-794-9700
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. JACK B MCEWAN
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Credential | DDS
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Telephone | 614-794-9700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QS0112X
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Taxonomy Name | Oral and Maxillofacial Surgery Clinic/Center
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License Number | 30022456
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License Number State | OH
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