Healthcare Provider Details

I. General information

NPI: 1528086352
Provider Name (Legal Business Name): ROCKY DON CULLENS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 12/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 WEST STONEWOOD DRIVE
BROKEN ARROW OK
74012
US

IV. Provider business mailing address

425 WEST STONE WOOD DRIVE
BROKEN ARROW OK
74012
US

V. Phone/Fax

Practice location:
  • Phone: 918-921-9003
  • Fax: 918-619-9006
Mailing address:
  • Phone: 918-921-9003
  • Fax: 918-615-9006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number3583
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number5601
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: