Healthcare Provider Details

I. General information

NPI: 1306257696
Provider Name (Legal Business Name): 59TH STREET DENTAL HEALTH CENTER, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2014
Last Update Date: 05/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 SW 59TH ST STE 105
OKLAHOMA CITY OK
73109-8322
US

IV. Provider business mailing address

309 SW 59TH ST STE 105
OKLAHOMA CITY OK
73109-8322
US

V. Phone/Fax

Practice location:
  • Phone: 405-631-2700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6574
License Number StateOK

VIII. Authorized Official

Name: TRAVIS BOYER
Title or Position: OWNER
Credential:
Phone: 405-631-2700