Provider Demographics
NPI:1619268265
Name:BLOOMINGTON ORAL & MAXILLOFACIAL SURGERY
Entity Type:Organization
Organization Name:BLOOMINGTON ORAL & MAXILLOFACIAL SURGERY
Other - Org Name:MARTINSVILLE ORAL & MAXILLOFACIAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:E
Authorized Official - Last Name:TATE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:812-323-9700
Mailing Address - Street 1:509 STATE ROAD 39 BYP S
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46151-1972
Mailing Address - Country:US
Mailing Address - Phone:765-352-9700
Mailing Address - Fax:765-352-9701
Practice Address - Street 1:509 STATE ROAD 39 BYP S
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46151-1972
Practice Address - Country:US
Practice Address - Phone:765-352-9700
Practice Address - Fax:765-352-9701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-29
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120101961223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200448260Medicaid
V01269Medicare UPIN
228510Medicare PIN