1093818478 NPI number — SOUTHWIND ORAL AND FACIAL SURGERY LLC

Table of content: (NPI 1093818478)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093818478 NPI number — SOUTHWIND ORAL AND FACIAL SURGERY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHWIND ORAL AND FACIAL SURGERY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093818478
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2301 N. WALDRON
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUTCHINSON
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67502-1133
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
620-663-1141
Provider Business Mailing Address Fax Number:
620-663-1373

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2301 N. WALDRON
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUTCHINSON
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67502-1133
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-663-1141
Provider Business Practice Location Address Fax Number:
620-663-1373
Provider Enumeration Date:
09/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DYE
Authorized Official First Name:
JARED
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
620-663-1141

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  6423 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 022955 . This is a "BLUE CROSS & BLUE SHIELD" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".




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