Provider Demographics
NPI:1609841493
Name:LEAVENWORTH ORAL & MAXILLOFACIAL SURGEONS PA
Entity Type:Organization
Organization Name:LEAVENWORTH ORAL & MAXILLOFACIAL SURGEONS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:913-772-4334
Mailing Address - Street 1:3550 S 4TH ST
Mailing Address - Street 2:SUITE 240
Mailing Address - City:LEAVENWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:66048-5071
Mailing Address - Country:US
Mailing Address - Phone:913-772-4334
Mailing Address - Fax:913-772-0851
Practice Address - Street 1:3550 S 4TH ST
Practice Address - Street 2:SUITE 240
Practice Address - City:LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66048-5071
Practice Address - Country:US
Practice Address - Phone:913-772-4334
Practice Address - Fax:913-772-0851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS46721223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KST73575Medicare UPIN
KS019316EVMedicare ID - Type UnspecifiedDR. EVANS ID