Healthcare Provider Details

I. General information

NPI: 1053576959
Provider Name (Legal Business Name): MARY HAMBURG DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2008
Last Update Date: 12/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9112 N. MAY AVE.
OKLA.CITY OK
73120
US

IV. Provider business mailing address

9112 N. MAY AVE.
OKLA.CITY OK
73120
US

V. Phone/Fax

Practice location:
  • Phone: 405-947-0486
  • Fax: 405-942-4392
Mailing address:
  • Phone: 405-947-0486
  • Fax: 405-942-4392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6065
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: