Provider Demographics
NPI:1407809585
Name:INDIANA ORAL & MAXILLOFACIAL SURGERY ASSOCIATES PC
Entity Type:Organization
Organization Name:INDIANA ORAL & MAXILLOFACIAL SURGERY ASSOCIATES PC
Other - Org Name:INDIANA ORAL AND MAXILLOFACIAL SURGERY ASSOCIATES
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-913-2363
Mailing Address - Street 1:10972 ALLISONVILLE RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-2637
Mailing Address - Country:US
Mailing Address - Phone:317-913-2363
Mailing Address - Fax:317-913-2370
Practice Address - Street 1:10972 ALLISONVILLE RD
Practice Address - Street 2:SUITE 110
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46038-2637
Practice Address - Country:US
Practice Address - Phone:317-913-2363
Practice Address - Fax:317-913-2370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2017-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100059140Medicaid