=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720330004
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EAST CENTRAL INDIANA ORAL AND MAXILLOFACIAL SURGERY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2012
-----------------------------------------------------
Last Update Date | 10/10/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3895 N WHEELING AVE
-----------------------------------------------------
City | MUNCIE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47304-1776
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-281-1131
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3895 N WHEELING AVE
-----------------------------------------------------
City | MUNCIE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47304-1776
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-281-1131
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE CO-OWNER
-----------------------------------------------------
Name | DR. HARRY PAPADOPOULOS
-----------------------------------------------------
Credential | DDS, MD
-----------------------------------------------------
Telephone | 765-281-1131
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QS0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery Clinic/Center
-----------------------------------------------------
License Number | 12010966A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QS0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery Clinic/Center
-----------------------------------------------------
License Number | 12008702A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------