Healthcare Provider Details

I. General information

NPI: 1518755578
Provider Name (Legal Business Name): ORAL SURGEONS OF OKLAHOMA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2025
Last Update Date: 04/29/2025
Certification Date: 04/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1382 S DOUGLAS BLVD
MIDWEST CITY OK
73130-5215
US

IV. Provider business mailing address

1382 S DOUGLAS BLVD
MIDWEST CITY OK
73130-5215
US

V. Phone/Fax

Practice location:
  • Phone: 405-741-1962
  • Fax:
Mailing address:
  • Phone: 405-741-1962
  • 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: CASSIE WIETH
Title or Position: DIRECTOR OF PAYOR RELATIONS
Credential:
Phone: 623-267-8121