Provider Demographics
NPI:1649347832
Name:FORT WAYNE ORAL MAXILLOFACIAL SURGERY & IMPLANT CENTER, LLC
Entity type:Organization
Organization Name:FORT WAYNE ORAL MAXILLOFACIAL SURGERY & IMPLANT CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MULOKOZI
Authorized Official - Middle Name:K
Authorized Official - Last Name:LUGAKINGIRA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS, DDS
Authorized Official - Phone:260-490-2013
Mailing Address - Street 1:2121 E DUPONT RD
Mailing Address - Street 2:SUITE #C
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1546
Mailing Address - Country:US
Mailing Address - Phone:260-490-2013
Mailing Address - Fax:260-490-1081
Practice Address - Street 1:2121 E DUPONT RD
Practice Address - Street 2:SUITE #C
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1546
Practice Address - Country:US
Practice Address - Phone:260-490-2013
Practice Address - Fax:260-490-1081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2013-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201036240Medicaid
INM400059365Medicare PIN