Healthcare Provider Details

I. General information

NPI: 1013256635
Provider Name (Legal Business Name): LAKESIDE ORAL SURGERY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2013
Last Update Date: 02/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 W BRITTON RD SUITE A
OKLAHOMA CITY OK
73120-2058
US

IV. Provider business mailing address

3100 W BRITTON RD SUITE A
OKLAHOMA CITY OK
73120-2058
US

V. Phone/Fax

Practice location:
  • Phone: 405-751-3312
  • Fax: 405-751-3524
Mailing address:
  • Phone: 405-751-3312
  • Fax: 405-751-3524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: DR. LESTER L COWDEN III
Title or Position: OWNER
Credential: DDS
Phone: 405-751-3312