Healthcare Provider Details

I. General information

NPI: 1588923767
Provider Name (Legal Business Name): MR. LAHCEN ANDREW DALLALY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2012
Last Update Date: 08/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 N 31ST ST
CLINTON OK
73601-9116
US

IV. Provider business mailing address

105 SE 45TH ST
OKLAHOMA CITY OK
73129-3201
US

V. Phone/Fax

Practice location:
  • Phone: 580-323-6021
  • Fax:
Mailing address:
  • Phone: 405-634-4400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: