Healthcare Provider Details

I. General information

NPI: 1912640145
Provider Name (Legal Business Name): IMMEDIATE SMILES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2022
Last Update Date: 04/15/2022
Certification Date: 04/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11317 S WESTERN AVE STE 100B
OKLAHOMA CITY OK
73170-5848
US

IV. Provider business mailing address

11317 S WESTERN AVE STE 100B
OKLAHOMA CITY OK
73170-5848
US

V. Phone/Fax

Practice location:
  • Phone: 405-691-0155
  • Fax: 405-369-7330
Mailing address:
  • Phone: 405-691-0155
  • Fax: 405-369-7330

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: PERRY BROOKS
Title or Position: OWNER
Credential: DDS
Phone: 405-691-0155