Provider Demographics
NPI:1073855193
Name:BUCKEYE ORAL & MAXILLOFACIAL SURGEY
Entity type:Organization
Organization Name:BUCKEYE ORAL & MAXILLOFACIAL SURGEY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:B
Authorized Official - Last Name:MCEWAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:614-794-9700
Mailing Address - Street 1:PO BOX 2443
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43086-2443
Mailing Address - Country:US
Mailing Address - Phone:614-794-9700
Mailing Address - Fax:
Practice Address - Street 1:110 POLARIS PARKWAY
Practice Address - Street 2:SUITE 110
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43082-0000
Practice Address - Country:US
Practice Address - Phone:614-794-9700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-27
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30022456261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2711882Medicaid