Provider Demographics
NPI:1831264324
Name:ORAL & MAXILLOFACIAL SURGERY ASSOCIATES PC
Entity type:Organization
Organization Name:ORAL & MAXILLOFACIAL SURGERY ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CDA
Authorized Official - Prefix:
Authorized Official - First Name:CELESTE
Authorized Official - Middle Name:C
Authorized Official - Last Name:SHOLL
Authorized Official - Suffix:
Authorized Official - Credentials:CDA
Authorized Official - Phone:260-423-2340
Mailing Address - Street 1:7845 CARNEGIE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-5792
Mailing Address - Country:US
Mailing Address - Phone:260-969-4105
Mailing Address - Fax:260-969-4118
Practice Address - Street 1:7845 CARNEGIE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804
Practice Address - Country:US
Practice Address - Phone:260-969-4105
Practice Address - Fax:260-969-4118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN6185590001OtherDME MAC
IN6185590001OtherNGS DME MAC
IN200029030Medicaid
IN6185590001OtherNGS DME MAC
IN6185590001Medicare NSC