Healthcare Provider Details

I. General information

NPI: 1588725485
Provider Name (Legal Business Name): MICHAEL S BEN INC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 02/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 N 2ND STREET
FAIRFAX OK
74637
US

IV. Provider business mailing address

161 N 2ND STREET
FAIRFAX OK
74637
US

V. Phone/Fax

Practice location:
  • Phone: 918-642-3400
  • Fax: 918-642-3370
Mailing address:
  • Phone: 918-642-3400
  • Fax: 918-642-3370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MRS. KELLY LYNETTE HADLOCK
Title or Position: OFFICE MANAGER
Credential:
Phone: 918-642-3400