Healthcare Provider Details

I. General information

NPI: 1144304643
Provider Name (Legal Business Name): ORAL SURGERY KANSAS, LC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 01/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 MAINE ST
LAWRENCE KS
66044
US

IV. Provider business mailing address

308 MAINE ST
LAWRENCE KS
66044
US

V. Phone/Fax

Practice location:
  • Phone: 785-843-5490
  • Fax: 785-843-5378
Mailing address:
  • Phone: 785-843-5490
  • Fax: 785-843-5378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number6641
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number6112
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number60789
License Number StateKS
# 4
Primary TaxonomyN
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BRENDAN T. FARRELL
Title or Position: ORAL SURGEON
Credential: DDS
Phone: 785-843-5490