Provider Demographics
NPI:1720330004
Name:EAST CENTRAL INDIANA ORAL AND MAXILLOFACIAL SURGERY, LLC
Entity Type:Organization
Organization Name:EAST CENTRAL INDIANA ORAL AND MAXILLOFACIAL SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:PAPADOPOULOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MD
Authorized Official - Phone:765-281-1131
Mailing Address - Street 1:3895 N WHEELING AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-1776
Mailing Address - Country:US
Mailing Address - Phone:765-281-1131
Mailing Address - Fax:
Practice Address - Street 1:3895 N WHEELING AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-1776
Practice Address - Country:US
Practice Address - Phone:765-281-1131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-10
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010966A261QS0112X
IN12008702A261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery