Organization
ORAL & MAXILLOFACIAL SURGERY ASSOCIATES PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
CELESTE C SHOLL (CREDENTIALING COORDINATOR)
(260) 969-4113
Entity
Organization
Contact information
Practice address
7845 CARNEGIE BLVD, FORT WAYNE, IN 46804
(260) 969-4105
(260) 969-4118
Mailing address
7845 CARNEGIE BLVD, FORT WAYNE, IN 46804-5792
(260) 969-4105
(260) 969-4118
Taxonomy
Speciality
Code
Description
License number
State
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
—
—
204E00000X
Oral & Maxillofacial Surgery (D.M.D.)
—
—
363L00000X
Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200029030
—
IN
01
—
6185590001
DME MAC
IN
Enumeration date
11/21/2006
Last updated
08/18/2025
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