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General NPI Number Information
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NPI Number | 1093775272
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Entity Type | Organization
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Legal Business Name | MICHIANA ORAL &MAXILLOFACIAL SURGERY LLC
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Dates
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Enumeration Date | 03/23/2006
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Last Update Date | 04/18/2012
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Provider Practice Location Address
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Address Line | 707 N MICHIGAN ST SUITE 300
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City | SOUTH BEND
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State | IN
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Zip | 46601-1070
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Country | US
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Telephone | 574-289-0080
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Fax | 574-287-6320
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Provider Business Mailing Address
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Address Line | 707 N MICHIGAN ST SUITE 300
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City | SOUTH BEND
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State | IN
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Zip | 46601-1070
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Country | US
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Telephone | 574-289-0080
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Fax | 574-287-6320
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Authorized Official
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Title or Position | OWNER
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Name | BERNARD J ASDELL
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Credential | DDS
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Telephone | 574-289-0080
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 12008287
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License Number State | IN
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