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General NPI Number Information
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NPI Number | 1649347832
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Entity Type | Organization
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Legal Business Name | FORT WAYNE ORAL MAXILLOFACIAL SURGERY & IMPLANT CENTER, LLC
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Dates
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Enumeration Date | 11/30/2006
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Last Update Date | 10/07/2013
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Provider Practice Location Address
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Address Line | 2121 E DUPONT RD SUITE #C
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City | FORT WAYNE
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State | IN
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Zip | 46825-1546
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Country | US
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Telephone | 260-490-2013
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Fax | 260-490-1081
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Provider Business Mailing Address
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Address Line | 2121 E DUPONT RD SUITE #C
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City | FORT WAYNE
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State | IN
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Zip | 46825-1546
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Country | US
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Telephone | 260-490-2013
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Fax | 260-490-1081
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MULOKOZI K. LUGAKINGIRA
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Credential | DMD, MS, DDS
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Telephone | 260-490-2013
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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 |
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License Number State | IN
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