Provider Demographics
NPI:1992159552
Name:KOKOMO IMPLANT AND ORAL SURGERY, LLC
Entity type:Organization
Organization Name:KOKOMO IMPLANT AND ORAL SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:S
Authorized Official - Last Name:BEARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-841-1100
Mailing Address - Street 1:9860 WESTPOINT DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-3398
Mailing Address - Country:US
Mailing Address - Phone:317-841-1100
Mailing Address - Fax:317-841-2200
Practice Address - Street 1:2008 WEST SYCAMORE STREET
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46901-4112
Practice Address - Country:US
Practice Address - Phone:795-452-0033
Practice Address - Fax:765-457-2175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-20
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010961A1223S0112X
IN12012362A1223S0112X
IN12007255A1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty