Healthcare Provider Details

I. General information

NPI: 1740468305
Provider Name (Legal Business Name): HEARTLAND DENTAL CARE OF OKLAHOMA, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2008
Last Update Date: 03/15/2023
Certification Date: 03/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

735 E KENOSHA ST
BROKEN ARROW OK
74012-2029
US

IV. Provider business mailing address

735 E KENOSHA ST
BROKEN ARROW OK
74012-2029
US

V. Phone/Fax

Practice location:
  • Phone: 918-251-1521
  • Fax: 918-258-4226
Mailing address:
  • Phone: 918-251-1521
  • Fax: 918-258-4226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3831
License Number StateOK

VIII. Authorized Official

Name: BELINDA HUERTA
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 217-540-2100