Healthcare Provider Details

I. General information

NPI: 1730460270
Provider Name (Legal Business Name): LAKEWOOD ORAL AND MAXILLOFACIAL SURGERY SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2011
Last Update Date: 08/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 NE RALPH POWELL RD SUITE D
LEES SUMMIT MO
64064-2369
US

IV. Provider business mailing address

3600 NE RALPH POWELL RD SUITE D
LEES SUMMIT MO
64064-2369
US

V. Phone/Fax

Practice location:
  • Phone: 816-554-8300
  • Fax: 816-554-8303
Mailing address:
  • Phone: 816-554-8300
  • Fax: 816-554-8303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2002013152
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number60577
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number04-34622
License Number StateKS
# 4
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number2008034915
License Number StateMO

VIII. Authorized Official

Name: DR. CHRISTOPHER J HAGGERTY
Title or Position: MEMBER
Credential: DDS, MD
Phone: 816-554-8300