Provider Demographics
NPI:1891350575
Name:BLOOMINGTON ORAL SURGERY
Entity Type:Organization
Organization Name:BLOOMINGTON ORAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ORAL SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:JACOB
Authorized Official - Last Name:DEVITT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:812-332-2204
Mailing Address - Street 1:1116 S COLLEGE MALL RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-6178
Mailing Address - Country:US
Mailing Address - Phone:812-332-2204
Mailing Address - Fax:812-332-9095
Practice Address - Street 1:1116 S COLLEGE MALL RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-6178
Practice Address - Country:US
Practice Address - Phone:812-332-2204
Practice Address - Fax:812-332-9095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-07
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1164475323Medicaid