Healthcare Provider Details

I. General information

NPI: 1023179009
Provider Name (Legal Business Name): ALLEN W. SUMMERLIN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 06/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NW 9TH ST
CHECOTAH OK
74426-3018
US

IV. Provider business mailing address

2716 E 39TH PL
TULSA OK
74105-8209
US

V. Phone/Fax

Practice location:
  • Phone: 918-473-3700
  • Fax:
Mailing address:
  • Phone: 918-453-8335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5624
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: