MEDICARE: TULSA CITY DENTAL TCD, PLLC

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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1154156172
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TULSA CITY DENTAL TCD, PLLC

Provider Business Mailing Address
First Line	:	14001 S JOPLIN AVE
Second Line	:
City	:	BIXBY
State	:	OK
Zip	:	74008-4155
Country	:	US
Telephone Number	:	951-533-0163
Fax Number	:

Provider Business Practice Location Address
First Line	:	5639 E 41ST ST
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74135-6010
Country	:	US
Telephone Number	:	918-622-3353
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. CHRISTIAN ANDRUS
Credential	:	DMD
Telephone Number	:	951-533-0163

Provider Enumeration Date	:	09/09/2024
Last Update Date	:	09/09/2024

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