MEDICARE: MONESMITH & WOOD ORAL AND MAXILLOFACIAL SURGERY 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)	12009891A	IN
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	12009137	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000351646	OTHER	IN	ANTHEM
2	000000093454	OTHER	IN	ANTHEM

General Provider Information

NPI Number	:	1205854791
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MONESMITH & WOOD ORAL AND MAXILLOFACIAL SURGERY PC

Provider Business Mailing Address
First Line	:	2005 ST CHARLES STREET
Second Line	:	SUITE 2
City	:	JASPER
State	:	IN
Zip	:	47546-9146
Country	:	US
Telephone Number	:	812-482-2280
Fax Number	:	812-482-4218

Provider Business Practice Location Address
First Line	:	2005 ST CHARLES STREET
Second Line	:	SUITE 2
City	:	JASPER
State	:	IN
Zip	:	47546-9146
Country	:	US
Telephone Number	:	812-482-2280
Fax Number	:	812-482-4218

Authorized Official
Title or Position	:	PRESIDENT ORAL SURGEON
Name	:	DR. MATTHEW BRIAN MONESMITH
Credential	:	DDS
Telephone Number	:	812-482-2280

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	08/22/2020

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