Healthcare Provider Details

I. General information

NPI: 1588404958
Provider Name (Legal Business Name): DSO PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2024
Last Update Date: 05/31/2024
Certification Date: 05/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10914 HEFNER POINTE DR STE 200
OKLAHOMA CITY OK
73120-5069
US

IV. Provider business mailing address

10914 HEFNER POINTE DR STE 200
OKLAHOMA CITY OK
73120-5069
US

V. Phone/Fax

Practice location:
  • Phone: 405-463-3337
  • Fax: 405-463-3338
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW DIESSELHORST
Title or Position: OWNER
Credential: MD
Phone: 405-463-3337