Provider Demographics
NPI:1093775272
Name:MICHIANA ORAL &MAXILLOFACIAL SURGERY LLC
Entity Type:Organization
Organization Name:MICHIANA ORAL &MAXILLOFACIAL SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:ASDELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:574-289-0080
Mailing Address - Street 1:707 N MICHIGAN ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-1070
Mailing Address - Country:US
Mailing Address - Phone:574-289-0080
Mailing Address - Fax:574-287-6320
Practice Address - Street 1:707 N MICHIGAN ST
Practice Address - Street 2:SUITE 300
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1070
Practice Address - Country:US
Practice Address - Phone:574-289-0080
Practice Address - Fax:574-287-6320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120082871223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100409820AMedicaid
IN210990Medicare PIN