Provider Demographics
NPI:1891973541
Name:ELKHART ORAL AND MAXILLOFACIAL SURGERY INC.
Entity Type:Organization
Organization Name:ELKHART ORAL AND MAXILLOFACIAL SURGERY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:S
Authorized Official - Last Name:MCBRIDE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:574-293-8211
Mailing Address - Street 1:117 S NAPPANEE ST
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-1955
Mailing Address - Country:US
Mailing Address - Phone:574-293-8211
Mailing Address - Fax:574-295-8270
Practice Address - Street 1:117 S NAPPANEE ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-1955
Practice Address - Country:US
Practice Address - Phone:574-293-8211
Practice Address - Fax:574-295-8270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-05
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120089261223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200310500AMedicaid