Provider Demographics
NPI:1235248329
Name:ORAL AND MAXILLOFACIAL SURGERY, P.C.
Entity Type:Organization
Organization Name:ORAL AND MAXILLOFACIAL SURGERY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:E
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-662-2068
Mailing Address - Street 1:1612 N BALDWIN AVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-1872
Mailing Address - Country:US
Mailing Address - Phone:765-662-2068
Mailing Address - Fax:765-662-3210
Practice Address - Street 1:1612 N BALDWIN AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-1872
Practice Address - Country:US
Practice Address - Phone:765-662-2068
Practice Address - Fax:765-662-3210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1223S0112X1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN=========-001OtherBLUE CROSS BLUE SHIELD
IN=========-001OtherBLUE CROSS BLUE SHIELD