Healthcare Provider Details

I. General information

NPI: 1396402442
Provider Name (Legal Business Name): LAHARI VATTIKUNTA B.D.S, M.S, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2021
Last Update Date: 11/09/2023
Certification Date: 03/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

765 N ASPEN AVE
BROKEN ARROW OK
74012-2224
US

IV. Provider business mailing address

765 N ASPEN AVE
BROKEN ARROW OK
74012-2224
US

V. Phone/Fax

Practice location:
  • Phone: 918-451-2717
  • Fax:
Mailing address:
  • Phone: 918-451-2717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number86
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: