Provider Demographics
NPI:1790105203
Name:RICHMOND ORAL & MAXILLOFACIAL SURGERY,LLC
Entity Type:Organization
Organization Name:RICHMOND ORAL & MAXILLOFACIAL SURGERY,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:S
Authorized Official - Last Name:BEARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-841-1100
Mailing Address - Street 1:1004 OAK DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1916
Mailing Address - Country:US
Mailing Address - Phone:765-935-1997
Mailing Address - Fax:765-939-2861
Practice Address - Street 1:1004 OAK DR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-1916
Practice Address - Country:US
Practice Address - Phone:765-935-1997
Practice Address - Fax:765-939-2861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-23
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010961A1223S0112X
IN12010160A1223S0112X
IN12011603A1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INPENDINGMedicaid