Healthcare Provider Details

I. General information

NPI: 1811512676
Provider Name (Legal Business Name): KYLE ROBERT MICHELSEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2020
Last Update Date: 06/08/2020
Certification Date: 06/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2750 NW 23RD ST
OKLAHOMA CITY OK
73107-2212
US

IV. Provider business mailing address

8305 NW 86TH ST
OKLAHOMA CITY OK
73132-3234
US

V. Phone/Fax

Practice location:
  • Phone: 405-942-4445
  • Fax:
Mailing address:
  • Phone: 405-697-8695
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberT-7317
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: