Healthcare Provider Details

I. General information

NPI: 1043886278
Provider Name (Legal Business Name): NICHOLAS NOVAKOVICH DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2021
Last Update Date: 05/28/2021
Certification Date: 05/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6616 S WESTERN AVE
OKLAHOMA CITY OK
73139-1708
US

IV. Provider business mailing address

400 RIVERWALK TER STE 250
JENKS OK
74037-5619
US

V. Phone/Fax

Practice location:
  • Phone: 405-601-7852
  • Fax: 405-601-7879
Mailing address:
  • Phone: 918-998-0996
  • Fax: 918-310-1056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number7461
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: