=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932999877
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INDIANA ORAL AND FACIAL SURGERY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2025
-----------------------------------------------------
Last Update Date | 05/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5120 CHARLESTOWN RD STE 1
-----------------------------------------------------
City | NEW ALBANY
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47150-9497
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-944-4000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3700 INGLESIDE BLVD
-----------------------------------------------------
City | LADSON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29456-4141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF RCM
-----------------------------------------------------
Name | JACKIE HOLLOWAY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 854-200-7970
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------