Healthcare Provider Details

I. General information

NPI: 1528072329
Provider Name (Legal Business Name): TERRY JACK FRUITS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 N STONEWALL AVE
OKLAHOMA CITY OK
73117-1214
US

IV. Provider business mailing address

1201 N STONEWALL AVE
OKLAHOMA CITY OK
73117-1214
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-5735
  • Fax: 405-271-3006
Mailing address:
  • Phone: 405-271-5735
  • Fax: 405-271-3006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4026
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: