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General NPI Number Information
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NPI Number | 1104584515
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Entity Type | Organization
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Legal Business Name | WK ORAL AND MAXILLOFACIAL SURGERY INSTITUTE
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Dates
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Enumeration Date | 12/02/2021
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Last Update Date | 12/02/2021
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Provider Practice Location Address
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Address Line | 2508 BERT KOUNS INDUSTRIAL LOOP STE 410
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City | SHREVEPORT
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State | LA
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Zip | 71118-3157
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Country | US
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Telephone | 318-716-4939
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Fax |
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Provider Business Mailing Address
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Address Line | 2508 BERT KOUNS INDUSTRIAL LOOP STE 410
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City | SHREVEPORT
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State | LA
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Zip | 71118-3157
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Country | US
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Telephone | 318-716-4939
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Fax |
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Authorized Official
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Title or Position | SENIOR VP FINANCE
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Name | MARY JANE WARD
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Credential |
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Telephone | 318-716-4937
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number |
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License Number State |
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