Provider Demographics
NPI:1881887065
Name:EDISON LAKES ORAL SURGERY, P.C.
Entity type:Organization
Organization Name:EDISON LAKES ORAL SURGERY, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:574-272-8823
Mailing Address - Street 1:3367 DOUGLAS RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1779
Mailing Address - Country:US
Mailing Address - Phone:574-272-8823
Mailing Address - Fax:574-277-1837
Practice Address - Street 1:3367 DOUGLAS RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1779
Practice Address - Country:US
Practice Address - Phone:574-272-8823
Practice Address - Fax:574-277-1837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-22
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223S0112X
IN12010802A261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty