Provider Demographics
NPI:1588878326
Name:NOBLESVILLE ORAL & MAXILLOFACIAL SURGERY, PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:NOBLESVILLE ORAL & MAXILLOFACIAL SURGERY, PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:FAITH
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-776-0105
Mailing Address - Street 1:340 LOGAN ST
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46060-1432
Mailing Address - Country:US
Mailing Address - Phone:317-776-0105
Mailing Address - Fax:317-776-0348
Practice Address - Street 1:340 LOGAN ST
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-1432
Practice Address - Country:US
Practice Address - Phone:317-776-0105
Practice Address - Fax:317-776-0348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120092611223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200212660Medicaid
IN200212660Medicaid