Healthcare Provider Details

I. General information

NPI: 1053986935
Provider Name (Legal Business Name): LIVE OAK ORAL SURGERY OF OKLAHOMA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2021
Last Update Date: 05/24/2021
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5405 SW DAUN
LAWTON OK
73505-8508
US

IV. Provider business mailing address

PO BOX 258841
OKLAHOMA CITY OK
73125-8841
US

V. Phone/Fax

Practice location:
  • Phone: 580-699-3131
  • Fax: 580-699-3151
Mailing address:
  • Phone: 580-699-3131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL J GLIDDON
Title or Position: OWNER
Credential: DDS
Phone: 580-699-3131