Healthcare Provider Details

I. General information

NPI: 1629995493
Provider Name (Legal Business Name): RUKHSAR ULLAH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2026
Last Update Date: 07/02/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2005 NOVATE LN, EDMOND
EDMOND OK
73034
US

IV. Provider business mailing address

2005 NOVATE LN, EDMOND
EDMOND OK
73034
US

V. Phone/Fax

Practice location:
  • Phone: 313-742-4179
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number8248
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: