Provider Demographics
NPI:1689647018
Name:INSTITUTE OF JAW AND FACIAL SURGERY INC
Entity Type:Organization
Organization Name:INSTITUTE OF JAW AND FACIAL SURGERY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:N
Authorized Official - Last Name:SUNDHEIMER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:330-493-1605
Mailing Address - Street 1:4181 HOLIDAY ST NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2531
Mailing Address - Country:US
Mailing Address - Phone:330-493-1605
Mailing Address - Fax:330-493-9308
Practice Address - Street 1:4181 HOLIDAY ST NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2531
Practice Address - Country:US
Practice Address - Phone:330-493-1605
Practice Address - Fax:330-493-9308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-08
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0524534Medicaid
OH0733255Medicaid
OH0600433Medicaid
OH9279131Medicare PIN
OHU19505Medicare UPIN
OH0600433Medicaid
OHT47925Medicare UPIN
OH0524534Medicaid