Healthcare Provider Details

I. General information

NPI: 1295559557
Provider Name (Legal Business Name): RESTORATION DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2024
Last Update Date: 11/13/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E MEMORIAL RD SUITE 100
EDMOND OK
73114
US

IV. Provider business mailing address

101 E MEMORIAL RD SUITE 100
EDMOND OK
73114
US

V. Phone/Fax

Practice location:
  • Phone: 405-517-2175
  • Fax:
Mailing address:
  • Phone: 405-517-2175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. AARON COHENOUR
Title or Position: OWNER/DENTIST
Credential:
Phone: 405-517-2175