Healthcare Provider Details

I. General information

NPI: 1508564774
Provider Name (Legal Business Name): ZACHARY D NORTCH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2023
Last Update Date: 08/21/2023
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11476 S UNION ST STE 102
JENKS OK
74037-6909
US

IV. Provider business mailing address

2305 E WINSTON ST
BROKEN ARROW OK
74011-7473
US

V. Phone/Fax

Practice location:
  • Phone: 918-417-6511
  • Fax:
Mailing address:
  • Phone: 936-645-8264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number7793
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: