Provider Demographics
NPI:1942426341
Name:EAST INDIANAPOLIS ORAL AND MAXILLOFACIAL SURGERY
Entity Type:Organization
Organization Name:EAST INDIANAPOLIS ORAL AND MAXILLOFACIAL SURGERY
Other - Org Name:STEVEN C. GRAHAM, DDS, MATTHEW C. MOLL, DDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:C
Authorized Official - Last Name:MOLL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-353-1320
Mailing Address - Street 1:125 N SHORTRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4908
Mailing Address - Country:US
Mailing Address - Phone:317-353-1320
Mailing Address - Fax:317-359-5243
Practice Address - Street 1:125 N SHORTRIDGE RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-4908
Practice Address - Country:US
Practice Address - Phone:317-353-1320
Practice Address - Fax:317-359-5243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty