Provider Demographics
NPI:1992124879
Name:ORAL SURGERY CENTER OF KOKOMO LLC
Entity type:Organization
Organization Name:ORAL SURGERY CENTER OF KOKOMO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:LADD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:765-453-7710
Mailing Address - Street 1:3415 S LAFOUNTAIN ST
Mailing Address - Street 2:SUITE H
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-3802
Mailing Address - Country:US
Mailing Address - Phone:765-453-7710
Mailing Address - Fax:
Practice Address - Street 1:3415 S LAFOUNTAIN ST
Practice Address - Street 2:SUITE H
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-3802
Practice Address - Country:US
Practice Address - Phone:765-453-7710
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-08
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012039A1223P0106X, 1223S0112X, 261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty
No261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial SurgeryGroup - Single Specialty