Provider Demographics
NPI:1881258366
Name:MID-KANSAS ORAL & MAXILLOFACIAL SURGERY, LLC
Entity type:Organization
Organization Name:MID-KANSAS ORAL & MAXILLOFACIAL SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:GAGNON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:316-722-0800
Mailing Address - Street 1:3510 N RIDGE RD STE 500
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67205-1226
Mailing Address - Country:US
Mailing Address - Phone:316-722-0800
Mailing Address - Fax:
Practice Address - Street 1:3510 N RIDGE RD STE 500
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67205-1226
Practice Address - Country:US
Practice Address - Phone:316-722-0800
Practice Address - Fax:316-722-5822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-30
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty