Healthcare Provider Details

I. General information

NPI: 1487684338
Provider Name (Legal Business Name): TEJ D. LAD DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 09/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8194 E 111TH ST S
BIXBY OK
74008-2421
US

IV. Provider business mailing address

8194 E 111TH ST S
BIXBY OK
74008-2421
US

V. Phone/Fax

Practice location:
  • Phone: 918-369-6118
  • Fax: 918-369-6121
Mailing address:
  • Phone: 918-369-6118
  • Fax: 918-369-6121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5667
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: