Provider Demographics
NPI:1104584515
Name:WK ORAL AND MAXILLOFACIAL SURGERY INSTITUTE
Entity type:Organization
Organization Name:WK ORAL AND MAXILLOFACIAL SURGERY INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VP FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-716-4937
Mailing Address - Street 1:2508 BERT KOUNS INDUSTRIAL LOOP STE 410
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-3157
Mailing Address - Country:US
Mailing Address - Phone:318-716-4939
Mailing Address - Fax:
Practice Address - Street 1:2508 BERT KOUNS INDUSTRIAL LOOP STE 410
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3157
Practice Address - Country:US
Practice Address - Phone:318-716-4939
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-02
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty