Provider Demographics
NPI:1033384268
Name:CENTER FOR ORAL & MAXILLOFACIAL SURGERY
Entity Type:Organization
Organization Name:CENTER FOR ORAL & MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:ERDELJAC
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:419-423-4651
Mailing Address - Street 1:1816 CHAPEL DR
Mailing Address - Street 2:SUITE H
Mailing Address - City:FINDLAY
Mailing Address - State:OH
Mailing Address - Zip Code:45840-1331
Mailing Address - Country:US
Mailing Address - Phone:419-423-4651
Mailing Address - Fax:
Practice Address - Street 1:1816 CHAPEL DR
Practice Address - Street 2:SUITE H
Practice Address - City:FINDLAY
Practice Address - State:OH
Practice Address - Zip Code:45840
Practice Address - Country:US
Practice Address - Phone:419-423-4651
Practice Address - Fax:419-423-4320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2021-10-06
Deactivation Date:2018-04-24
Deactivation Code:
Reactivation Date:2020-02-26
Provider Licenses
StateLicense IDTaxonomies
OH215531223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2470302Medicaid
OH2470302Medicaid
OHU95606Medicare UPIN