Provider Demographics
NPI:1174534515
Name:FISHERS ORAL & MAXILLOFACIAL SURGERY
Entity type:Organization
Organization Name:FISHERS ORAL & MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-849-3667
Mailing Address - Street 1:9126 TECHNOLOGY LN
Mailing Address - Street 2:STE 300
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-3064
Mailing Address - Country:US
Mailing Address - Phone:317-849-3667
Mailing Address - Fax:317-849-3668
Practice Address - Street 1:9126 TECHNOLOGY LN
Practice Address - Street 2:STE 300
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46038-3064
Practice Address - Country:US
Practice Address - Phone:317-849-3667
Practice Address - Fax:317-849-3668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120077581223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OTH000Medicare UPIN