MEDICARE: DR. CHRISTIAN SHAUN MIRABAL DDS

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	122300000X	Dentist	6682	OK

General Provider Information

NPI Number	:	1023484284
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHRISTIAN SHAUN MIRABAL DDS

Provider Business Mailing Address
First Line	:	3150 E 41ST ST STE 131
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74105-3758
Country	:	US
Telephone Number	:	918-749-1639
Fax Number	:	918-749-0416

Provider Business Practice Location Address
First Line	:	3150 E 41ST ST STE 131
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74105-3758
Country	:	US
Telephone Number	:	918-749-1639
Fax Number	:	918-749-0416

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/11/2015
Last Update Date	:	09/24/2018

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