Provider Demographics
NPI:1841505252
Name:BLOOMINGTON ORAL SURGERY LLC
Entity type:Organization
Organization Name:BLOOMINGTON ORAL SURGERY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:DEVITT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:812-332-2204
Mailing Address - Street 1:857 S AUTO MALL RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-5447
Mailing Address - Country:US
Mailing Address - Phone:812-332-2204
Mailing Address - Fax:821-332-9095
Practice Address - Street 1:857 S AUTO MALL RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-5447
Practice Address - Country:US
Practice Address - Phone:812-332-2204
Practice Address - Fax:821-332-9095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-10
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0652A1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200809540AMedicaid