Healthcare Provider Details

I. General information

NPI: 1306076971
Provider Name (Legal Business Name): WAKARUSA ORAL SURGERY, LC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2009
Last Update Date: 07/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 LEGENDS DR
LAWRENCE KS
66049-5800
US

IV. Provider business mailing address

4901 LEGENDS DR
LAWRENCE KS
66049-5800
US

V. Phone/Fax

Practice location:
  • Phone: 785-856-6010
  • Fax:
Mailing address:
  • Phone: 785-856-6010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number6706
License Number StateKS

VIII. Authorized Official

Name: PHILIP CHARLES GAUS JR.
Title or Position: MANAGER/MEMBER
Credential: DDS
Phone: 785-856-6010