Provider Demographics
NPI:1154411163
Name:ORAL AND MAXILLOFACIAL SURGERY CENTER OF LAFAYETTE
Entity type:Organization
Organization Name:ORAL AND MAXILLOFACIAL SURGERY CENTER OF LAFAYETTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-446-8808
Mailing Address - Street 1:2020 UNION STREET
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904
Mailing Address - Country:US
Mailing Address - Phone:765-446-8808
Mailing Address - Fax:765-446-9567
Practice Address - Street 1:2020 UNION STREET
Practice Address - Street 2:SUITE 200
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904
Practice Address - Country:US
Practice Address - Phone:765-446-8808
Practice Address - Fax:765-446-9567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2009-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty