=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861209694
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STUART ORAL SURGERY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/16/2024
-----------------------------------------------------
Last Update Date | 12/16/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8240 NAAB RD STE 355
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46260-1987
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-876-1095
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9499 ABERDARE DR
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46250-3406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-752-8857
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. RICHARD JOSEPH STUART III
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 317-752-8857
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------