Healthcare Provider Details

I. General information

NPI: 1821586603
Provider Name (Legal Business Name): WALDO ORAL SURGERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2018
Last Update Date: 04/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8043 WORNALL RD STE 201
KANSAS CITY MO
64114-5822
US

IV. Provider business mailing address

8043 WORNALL RD STE 201
KANSAS CITY MO
64114-5822
US

V. Phone/Fax

Practice location:
  • Phone: 816-214-8339
  • Fax: 816-216-1742
Mailing address:
  • Phone: 816-214-8339
  • Fax: 816-216-1742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2016011725
License Number StateMO

VIII. Authorized Official

Name: MRS. ALICIA A TAMBURELLO
Title or Position: REGIONAL MANAGER OF BILLING & INS
Credential:
Phone: 816-830-9030