Healthcare Provider Details

I. General information

NPI: 1982964045
Provider Name (Legal Business Name): SOREN CHASE MICHAELSEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2012
Last Update Date: 05/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1755 N HIGHWAY 66 SUITE C
CATOOSA OK
74015
US

IV. Provider business mailing address

2036 S. MILLER LANE SUITE #B
CATOOSA OK
74015
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:
Title or Position:
Credential:
Phone: