Healthcare Provider Details

I. General information

NPI: 1386412328
Provider Name (Legal Business Name): ADVANTAGE DENTAL ORAL HEALTH CENTER OF OKLAHOMA, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2023
Last Update Date: 03/19/2024
Certification Date: 03/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2619 S ELM PL
BROKEN ARROW OK
74012-7878
US

IV. Provider business mailing address

63140 BRITTA ST STE D104
BEND OR
97703-5738
US

V. Phone/Fax

Practice location:
  • Phone: 918-872-0218
  • Fax: 918-872-0892
Mailing address:
  • Phone: 629-999-5014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: SHERRIE EDMONDSON
Title or Position: SR MANAGER
Credential:
Phone: 629-999-5014