Provider Demographics
NPI:1093818478
Name:SOUTHWIND ORAL AND FACIAL SURGERY LLC
Entity Type:Organization
Organization Name:SOUTHWIND ORAL AND FACIAL SURGERY LLC
Other - Org Name:SOUTHWIND ORAL AND FACIAL SURGERY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JARED
Authorized Official - Middle Name:
Authorized Official - Last Name:DYE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-663-1141
Mailing Address - Street 1:2301 N. WALDRON
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON
Mailing Address - State:KS
Mailing Address - Zip Code:67502-1133
Mailing Address - Country:US
Mailing Address - Phone:620-663-1141
Mailing Address - Fax:620-663-1373
Practice Address - Street 1:2301 N. WALDRON
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:KS
Practice Address - Zip Code:67502-1133
Practice Address - Country:US
Practice Address - Phone:620-663-1141
Practice Address - Fax:620-663-1373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS64231223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS022955OtherBLUE CROSS & BLUE SHIELD
KST44090Medicare UPIN
KS017217Medicare ID - Type UnspecifiedHUTCHINSON OFFICE