MEDICARE: WK ORAL AND MAXILLOFACIAL SURGERY INSTITUTE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)

General Provider Information

NPI Number	:	1104584515
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WK ORAL AND MAXILLOFACIAL SURGERY INSTITUTE

Provider Business Mailing Address
First Line	:	2508 BERT KOUNS INDUSTRIAL LOOP STE 410
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71118-3157
Country	:	US
Telephone Number	:	318-716-4939
Fax Number	:

Provider Business Practice Location Address
First Line	:	2508 BERT KOUNS INDUSTRIAL LOOP STE 410
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71118-3157
Country	:	US
Telephone Number	:	318-716-4939
Fax Number	:

Authorized Official
Title or Position	:	SENIOR VP FINANCE
Name	:	MARY JANE WARD
Credential	:
Telephone Number	:	318-716-4937

Provider Enumeration Date	:	12/02/2021
Last Update Date	:	03/04/2026

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