Healthcare Provider Details

I. General information

NPI: 1699965194
Provider Name (Legal Business Name): ENDODONTIC PRACTICE ASSOCIATES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2007
Last Update Date: 07/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 24TH AVE SW SUITE 100
NORMAN OK
73069-3987
US

IV. Provider business mailing address

707 24TH AVE SW SUITE 100
NORMAN OK
73069-3987
US

V. Phone/Fax

Practice location:
  • Phone: 405-329-7936
  • Fax: 405-329-1722
Mailing address:
  • Phone: 405-329-7936
  • Fax: 405-329-1722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberP-25
License Number StateOK

VIII. Authorized Official

Name: MRS. SHERRY A SULLIVAN III
Title or Position: OFFICE MANAGER
Credential:
Phone: 405-329-7936