Healthcare Provider Details

I. General information

NPI: 1801898838
Provider Name (Legal Business Name): MARILYN JUNE HIEBERT D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 E STATE RD
FAIRVIEW OK
73737-1330
US

IV. Provider business mailing address

414 E STATE RD
FAIRVIEW OK
73737-1330
US

V. Phone/Fax

Practice location:
  • Phone: 580-227-4464
  • Fax: 580-227-4465
Mailing address:
  • Phone: 580-227-4464
  • Fax: 580-227-4465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4757
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: