=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205854791
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MONESMITH & WOOD ORAL AND MAXILLOFACIAL SURGERY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2005 ST CHARLES STREET SUITE 2
-----------------------------------------------------
City | JASPER
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47546-9146
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-482-2280
-----------------------------------------------------
Fax | 812-482-4218
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2005 ST CHARLES STREET SUITE 2
-----------------------------------------------------
City | JASPER
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47546-9146
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-482-2280
-----------------------------------------------------
Fax | 812-482-4218
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT ORAL SURGEON
-----------------------------------------------------
Name | DR. MATTHEW BRIAN MONESMITH
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 812-482-2280
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 12009891A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 12009137
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------