Provider Demographics
NPI:1003622150
Name:KLA IMPLANTS & ORAL SURGERY CENTER, PLLC
Entity type:Organization
Organization Name:KLA IMPLANTS & ORAL SURGERY CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO, ORAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:L
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:312-402-3250
Mailing Address - Street 1:970 WINDERMERE ROAD, BUILDING 11
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:970 WINDERMERE ROAD, BUILDING 11
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787
Practice Address - Country:US
Practice Address - Phone:312-402-3250
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-04
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty