Provider Demographics
NPI:1760461339
Name:SOUTH CENTRAL ORAL & MAXILLOFACIAL SURGERY, LLC
Entity Type:Organization
Organization Name:SOUTH CENTRAL ORAL & MAXILLOFACIAL SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:A
Authorized Official - Last Name:PLISKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:812-333-2614
Mailing Address - Street 1:2911 E COVENANTER DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-6320
Mailing Address - Country:US
Mailing Address - Phone:812-333-2614
Mailing Address - Fax:812-333-4594
Practice Address - Street 1:2911 E COVENANTER DR
Practice Address - Street 2:SUITE B
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-6320
Practice Address - Country:US
Practice Address - Phone:812-333-2614
Practice Address - Fax:812-333-4594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008000/120095821223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INU26591Medicare UPIN
INU66437Medicare UPIN
IN194860AMedicare ID - Type UnspecifiedDAVID HOWELL
IN194860BMedicare ID - Type UnspecifiedTIMOTHY PLISKE