Healthcare Provider Details

I. General information

NPI: 1487074704
Provider Name (Legal Business Name): EASTERN OKLAHOMA ORAL AND MAXILLOFACIAL SURGEONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2014
Last Update Date: 03/17/2018
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: 918-455-8958
Mailing address:
  • Phone: 918-449-5800
  • Fax: 918-455-8958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MS. ANGIE ROE
Title or Position: CREDENTIALING AND CONTRACTING
Credential:
Phone: 888-247-1869