Provider Demographics
NPI:1194920322
Name:SOUTHERN OHIO ORAL & FACIAL SURGEONS, INC.
Entity type:Organization
Organization Name:SOUTHERN OHIO ORAL & FACIAL SURGEONS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:SCHOONMAKER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:740-773-6159
Mailing Address - Street 1:36 N WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-3114
Mailing Address - Country:US
Mailing Address - Phone:740-773-6159
Mailing Address - Fax:740-773-1078
Practice Address - Street 1:36 N WALNUT ST
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-3114
Practice Address - Country:US
Practice Address - Phone:740-773-6159
Practice Address - Fax:740-773-1078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300197191223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2052442Medicaid