Healthcare Provider Details

I. General information

NPI: 1740233733
Provider Name (Legal Business Name): SOUTHERN OKLAHOMA EAR NOSE THROAT AND ALLGERY CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2002 12TH AVE NW SUITE D
ARDMORE OK
73401-1206
US

IV. Provider business mailing address

2002 12TH AVE NW SUITE D
ARDMORE OK
73401-1206
US

V. Phone/Fax

Practice location:
  • Phone: 580-226-8646
  • Fax: 580-226-8641
Mailing address:
  • Phone: 580-226-8646
  • Fax: 580-226-8641

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License Number20353
License Number StateOK

VIII. Authorized Official

Name: DR. SCOTT ALLEN DEMPEWOLF
Title or Position: OWNER
Credential: M.D.
Phone: 580-226-8646