Provider Demographics
NPI:1265479737
Name:AVON ORAL & MAXILLOFACIAL SURGERY LLP
Entity Type:Organization
Organization Name:AVON ORAL & MAXILLOFACIAL SURGERY LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:KINGERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-272-2200
Mailing Address - Street 1:6695 E US HIGHWAY 36
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-8923
Mailing Address - Country:US
Mailing Address - Phone:317-272-2200
Mailing Address - Fax:317-272-3714
Practice Address - Street 1:6695 E US HIGHWAY 36
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-8923
Practice Address - Country:US
Practice Address - Phone:317-272-2200
Practice Address - Fax:317-272-3714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200298930AMedicaid
IN200298930AMedicaid