Healthcare Provider Details

I. General information

NPI: 1396902854
Provider Name (Legal Business Name): ELMER J VAUGHT D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2008
Last Update Date: 05/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 N STONEWALL AVE RM 265
OKLAHOMA CITY OK
73117-1214
US

IV. Provider business mailing address

1201 N STONEWALL AVE RM 265
OKLAHOMA CITY OK
73117-1214
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-4711
  • Fax: 405-271-2922
Mailing address:
  • Phone: 405-271-4711
  • Fax: 405-271-2922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number4072
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: