Healthcare Provider Details

I. General information

NPI: 1912780560
Provider Name (Legal Business Name): ORAGEN LAWTON ORAL SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

3617 W GORE BLVD
LAWTON OK
73505-6373
US

IV. Provider business mailing address

3617 W GORE BLVD
LAWTON OK
73505-6373
US

V. Phone/Fax

Practice location:
  • Phone: 405-691-0155
  • Fax:
Mailing address:
  • Phone:
  • 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: WHITNEY PAVICK
Title or Position: SR. OPERATIONS MANAGER
Credential:
Phone: 801-857-7947