Healthcare Provider Details

I. General information

NPI: 1508073438
Provider Name (Legal Business Name): GREGORY D SEGRAVES D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4716 W URBANA ST STE 100
BROKEN ARROW OK
74012-6162
US

IV. Provider business mailing address

4716 W URBANA ST STE 100
BROKEN ARROW OK
74012-6162
US

V. Phone/Fax

Practice location:
  • Phone: 918-449-5800
  • Fax: 918-455-8958
Mailing address:
  • Phone: 918-449-5800
  • Fax: 918-455-8958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number141
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number5930
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: