Provider Demographics
NPI:1013171594
Name:CARMEL ORAL & MAXILLOFACIAL SURGERY
Entity Type:Organization
Organization Name:CARMEL ORAL & MAXILLOFACIAL SURGERY
Other - Org Name:CARMEL ORAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:C
Authorized Official - Last Name:JACHIMOWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-844-7626
Mailing Address - Street 1:13590B N MERIDIAN ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-1406
Mailing Address - Country:US
Mailing Address - Phone:317-844-7626
Mailing Address - Fax:317-844-3804
Practice Address - Street 1:13590B N MERIDIAN ST
Practice Address - Street 2:SUITE 105
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-1456
Practice Address - Country:US
Practice Address - Phone:317-844-7626
Practice Address - Fax:317-844-3804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-15
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009721A1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN217420Medicare PIN