Organization
LAFAYETTE ORAL AND MAXILLOFACIAL SURGERY GROUP, P.C.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. BRETT ANTHONY HENRIKSON D.D.S (PRESIDENT)
(765) 807-0230
Entity
Organization
Contact information
Practice address
2 EXECUTIVE DR, SUITE A, LAFAYETTE, IN 47905-4859
(765) 807-0230
(765) 807-0234
Mailing address
2 EXECUTIVE DR, SUITE A, LAFAYETTE, IN 47905-4859
(765) 807-0230
(765) 807-0234
Taxonomy
Speciality
Code
Description
License number
State
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
1201055A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
600000340871
ANTHEM BC/BS
IN
Enumeration date
10/19/2006
Last updated
08/22/2020
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