Healthcare Provider Details

I. General information

NPI: 1659436681
Provider Name (Legal Business Name): KEVIN O HALLORAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 N GLENN ENGLISH
CORDELL OK
73632
US

IV. Provider business mailing address

PO BOX 398 1211 N GLENN ENGLISH
CORDELL OK
73632
US

V. Phone/Fax

Practice location:
  • Phone: 580-832-3803
  • Fax: 580-832-3804
Mailing address:
  • Phone: 580-832-3803
  • Fax: 580-832-3804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4425
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: