Healthcare Provider Details

I. General information

NPI: 1194745620
Provider Name (Legal Business Name): FACIAL SURGERY GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 BELLEVIEW STE L 10
KANSAS CITY MO
64112-1360
US

IV. Provider business mailing address

PO BOX 802752
KANSAS CITY MO
64180-0001
US

V. Phone/Fax

Practice location:
  • Phone: 816-561-1115
  • Fax: 816-931-7912
Mailing address:
  • Phone: 816-561-1115
  • Fax: 816-753-4493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDE015216
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDE015905
License Number StateMO

VIII. Authorized Official

Name: MRS. LOUANN ALLEN
Title or Position: PRACTICE MANAGER
Credential:
Phone: 816-561-1115