Healthcare Provider Details

I. General information

NPI: 1629242573
Provider Name (Legal Business Name): REGGIE D. THOMAS, DMD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2008
Last Update Date: 04/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2109 W WASHINGTON ST
BROKEN ARROW OK
74012-6801
US

IV. Provider business mailing address

2109 W WASHINGTON ST
BROKEN ARROW OK
74012-6801
US

V. Phone/Fax

Practice location:
  • Phone: 918-455-0123
  • Fax: 918-455-2311
Mailing address:
  • Phone: 918-455-0123
  • Fax: 918-455-2311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number4739
License Number StateOK

VIII. Authorized Official

Name: VERONICA J. THOMAS
Title or Position: OFFICE MANAGER
Credential:
Phone: 918-455-0123