Healthcare Provider Details

I. General information

NPI: 1619162054
Provider Name (Legal Business Name): ROBERT BRIAN MOLLOY D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2007
Last Update Date: 01/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9801 S PENNSYLVANIA AVE
OKLAHOMA CITY OK
73159-6925
US

IV. Provider business mailing address

9801 S PENNSYLVANIA AVE
OKLAHOMA CITY OK
73159-6925
US

V. Phone/Fax

Practice location:
  • Phone: 405-692-1222
  • Fax: 405-703-0930
Mailing address:
  • Phone: 405-692-1222
  • Fax: 405-703-0930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number5436
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: