Healthcare Provider Details

I. General information

NPI: 1548432628
Provider Name (Legal Business Name): SOUTHWEST ORAL & MAXILLOFACIAL SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2008
Last Update Date: 07/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 CAMPUS DR SUITE 101
GARDEN CITY KS
67846-6294
US

IV. Provider business mailing address

311 CAMPUS DR SUITE 101
GARDEN CITY KS
67846-6294
US

V. Phone/Fax

Practice location:
  • Phone: 620-272-0100
  • Fax: 620-271-0160
Mailing address:
  • Phone: 620-272-0100
  • Fax: 620-271-0160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number StateKS

VIII. Authorized Official

Name: MRS. AMY HUXMAN
Title or Position: MANAGER
Credential:
Phone: 620-272-0100