Healthcare Provider Details

I. General information

NPI: 1922148345
Provider Name (Legal Business Name): GEORGE ROBERT BALLEW DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 W BROADWAY ST
MUSKOGEE OK
74401-2132
US

IV. Provider business mailing address

3201 W BROADWAY ST
MUSKOGEE OK
74401-2132
US

V. Phone/Fax

Practice location:
  • Phone: 918-686-6684
  • Fax: 918-686-6919
Mailing address:
  • Phone: 918-686-6684
  • Fax: 918-686-6919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4805
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: