Provider Demographics
NPI:1306076971
Name:WAKARUSA ORAL SURGERY, LC
Entity type:Organization
Organization Name:WAKARUSA ORAL SURGERY, LC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:GAUS
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:785-856-6010
Mailing Address - Street 1:4901 LEGENDS DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66049-5800
Mailing Address - Country:US
Mailing Address - Phone:785-856-6010
Mailing Address - Fax:
Practice Address - Street 1:4901 LEGENDS DR
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66049-5800
Practice Address - Country:US
Practice Address - Phone:785-856-6010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-17
Last Update Date:2009-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS67061223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100224610BMedicaid
KS100224610BMedicaid