Healthcare Provider Details

I. General information

NPI: 1598491086
Provider Name (Legal Business Name): DIVESH SARDANA MDS, MBA, MPH, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2022
Last Update Date: 07/27/2022
Certification Date: 07/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 N STONEWALL AVE RM 521B
OKLAHOMA CITY OK
73117-1214
US

IV. Provider business mailing address

1201 N STONEWALL AVE RM 521B
OKLAHOMA CITY OK
73117-1214
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-6056
  • Fax:
Mailing address:
  • Phone: 405-271-6056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberF-022
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: