Healthcare Provider Details

I. General information

NPI: 1821192212
Provider Name (Legal Business Name): GURBIR PAUL TIWANA D.M.D. M.D. M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 08/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 N LINCOLN BLVD # 2000
OKLAHOMA CITY OK
73104
US

IV. Provider business mailing address

2745 S I 35 SERVICE RD
MOORE OK
73160-2715
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-4955
  • Fax: 405-271-4525
Mailing address:
  • Phone: 405-261-1002
  • Fax: 405-493-0995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number8072
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number38750
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberF-25350
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: