Healthcare Provider Details

I. General information

NPI: 1386710242
Provider Name (Legal Business Name): LARSON RUSSELL KESO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 NORTHWEST 50TH
OKLAHOMA CITY OK
73112-5699
US

IV. Provider business mailing address

3501 NORTHWEST 50TH
OKLAHOMA CITY OK
73112-5699
US

V. Phone/Fax

Practice location:
  • Phone: 405-943-8333
  • Fax: 405-947-1579
Mailing address:
  • Phone: 405-943-8333
  • Fax: 405-947-1579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2625
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number37
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: