Healthcare Provider Details

I. General information

NPI: 1932458312
Provider Name (Legal Business Name): GREEN COUNTRY DENTAL ARTS OF CATOOSA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2012
Last Update Date: 08/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1755 N. HIGHWAY 66 SUITE C
CATOOSA OK
74015
UM

IV. Provider business mailing address

PO BOX 1980
CATOOSA OK
74015-1980
US

V. Phone/Fax

Practice location:
  • Phone: 918-266-6470
  • Fax: 918-266-6473
Mailing address:
  • Phone: 918-266-6470
  • Fax: 918-266-6473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6403
License Number StateOK

VIII. Authorized Official

Name: DR. SOREN CHASE MICHAELSEN
Title or Position: DENTIST
Credential: D.D.S.
Phone: 918-266-6470