Healthcare Provider Details

I. General information

NPI: 1609142827
Provider Name (Legal Business Name): BOARD OF REGENTS OF OK - COL OF DENTISTRY GRAD PERODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2012
Last Update Date: 04/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 N STONEWALL AVE RM DCS253
OKLAHOMA CITY OK
73117-1214
US

IV. Provider business mailing address

PO BOX 26901
OKLAHOMA CITY OK
73126-0901
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-6531
  • Fax: 405-271-2922
Mailing address:
  • Phone: 405-271-6531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: LISA ASCH
Title or Position: ASSOCIATE DIRECTOR RESARCH ADMIN
Credential:
Phone: 405-271-2090