Provider Demographics
NPI:1710366323
Name:TRI-STATE ORAL SURGERY, LLC
Entity Type:Organization
Organization Name:TRI-STATE ORAL SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:E
Authorized Official - Last Name:WOHLFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, PHD
Authorized Official - Phone:812-401-3500
Mailing Address - Street 1:405 BENTEE WES CT
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-4061
Mailing Address - Country:US
Mailing Address - Phone:812-401-3500
Mailing Address - Fax:812-401-3600
Practice Address - Street 1:405 BENTEE WES CT
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-4061
Practice Address - Country:US
Practice Address - Phone:812-401-3500
Practice Address - Fax:812-401-3600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-28
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009501A1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty