MEDICARE: NORTHWEST ORAL SURGEONS PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	54000342A	IN

General Provider Information

NPI Number	:	1134100902
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHWEST ORAL SURGEONS PC

Provider Business Mailing Address
First Line	:	601A W US HWY 30
Second Line	:
City	:	SCHERERVILLE
State	:	IN
Zip	:	46375-2656
Country	:	US
Telephone Number	:	219-322-0501
Fax Number	:	219-322-0577

Provider Business Practice Location Address
First Line	:	601A W US HWY 30
Second Line	:
City	:	SCHERERVILLE
State	:	IN
Zip	:	46375-2656
Country	:	US
Telephone Number	:	219-322-0501
Fax Number	:	219-322-0577

Authorized Official
Title or Position	:	OFFICER
Name	:	MR. PAUL L WOLF
Credential	:	DDS
Telephone Number	:	219-322-0501

Provider Enumeration Date	:	11/09/2005
Last Update Date	:	08/28/2007

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Directions to “NORTHWEST ORAL SURGEONS PC ” Practice Location

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