Healthcare Provider Details

I. General information

NPI: 1417187063
Provider Name (Legal Business Name): HEATH HARRIS EVANS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2009
Last Update Date: 06/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4716 W URBANA ST
BROKEN ARROW OK
74012-5997
US

IV. Provider business mailing address

4716 W URBANA ST
BROKEN ARROW OK
74012-5997
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number6153
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: