Healthcare Provider Details

I. General information

NPI: 1447660063
Provider Name (Legal Business Name): OMS OF SOUTHERN OKLAHOMA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2014
Last Update Date: 05/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1119 WALNUT DR 2
ARDMORE OK
73401-2364
US

IV. Provider business mailing address

PO BOX 108816
OKLAHOMA CITY OK
73101-8816
US

V. Phone/Fax

Practice location:
  • Phone: 580-226-1727
  • Fax: 580-226-9413
Mailing address:
  • Phone: 405-848-7974
  • Fax: 405-848-0033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number3389
License Number StateOK

VIII. Authorized Official

Name: MRS. KATHY S DRESHER
Title or Position: VP BILLING
Credential:
Phone: 405-848-7974