Healthcare Provider Details

I. General information

NPI: 1225847056
Provider Name (Legal Business Name): ADVANCED ENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2025
Last Update Date: 05/01/2025
Certification Date: 05/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 STONE WOOD DR
BROKEN ARROW OK
74012-1026
US

IV. Provider business mailing address

411 STONE WOOD DR
BROKEN ARROW OK
74012-1026
US

V. Phone/Fax

Practice location:
  • Phone: 918-924-5917
  • Fax:
Mailing address:
  • Phone: 918-922-2368
  • Fax: 918-922-2367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: BRADLEY RUSSELL MONS
Title or Position: PHYSICIAN
Credential: DO
Phone: 918-863-6275