Healthcare Provider Details

I. General information

NPI: 1538391214
Provider Name (Legal Business Name): MAYFLOWER ORAL AND MAXILLOFACIAL SURGERY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2009
Last Update Date: 08/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5600 N MAY AVE SUITE 250
OKLAHOMA CITY OK
73112-3973
US

IV. Provider business mailing address

675 PARAMOUNT DR SUITE 105
RAYNHAM MA
02767-5416
US

V. Phone/Fax

Practice location:
  • Phone: 405-848-7974
  • Fax: 405-848-0033
Mailing address:
  • Phone: 405-848-7974
  • Fax: 405-848-0033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN1855112
License Number StateMA

VIII. Authorized Official

Name: DR. NICHOLAS C VEGA
Title or Position: ORAL SURGEON
Credential: DDS
Phone: 405-848-7974