Healthcare Provider Details

I. General information

NPI: 1700403722
Provider Name (Legal Business Name): KANSAS CITY FACIAL AND ORAL SURGERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2020
Last Update Date: 06/26/2020
Certification Date: 06/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2931 NE INDEPENDENCE AVE.
LEES SUMMIT MO
64064-6406
US

IV. Provider business mailing address

117 SW SHORES DR
LEES SUMMIT MO
64064-4502
US

V. Phone/Fax

Practice location:
  • Phone: 816-598-8166
  • Fax:
Mailing address:
  • Phone: 816-510-5689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: BRIAN HOLLABAUGH
Title or Position: ORAL AND MAXILLOFACIAL SURGEON
Credential: MD, DDS
Phone: 816-598-8166