Provider Demographics
NPI:1699989434
Name:SOUTHERN INDIANA ORAL AND MAXILLOFACIAL SURGERY P.S.C.
Entity type:Organization
Organization Name:SOUTHERN INDIANA ORAL AND MAXILLOFACIAL SURGERY P.S.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DR/ORAL & MAXILLOFACIAL SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:DON
Authorized Official - Middle Name:
Authorized Official - Last Name:FORSEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:812-282-8467
Mailing Address - Street 1:207 SPARKS AVE
Mailing Address - Street 2:SUITE 002
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-3771
Mailing Address - Country:US
Mailing Address - Phone:812-282-8467
Mailing Address - Fax:812-282-3067
Practice Address - Street 1:207 SPARKS AVE
Practice Address - Street 2:SUITE 002
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-3771
Practice Address - Country:US
Practice Address - Phone:812-282-8467
Practice Address - Fax:812-282-3067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007773174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U88290Medicare UPIN
190590Medicare PIN