Healthcare Provider Details

I. General information

NPI: 1851713747
Provider Name (Legal Business Name): MARIA FERNANDA SANTOS PERES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2014
Last Update Date: 01/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 N STONEWALL AVE RM 542
OKLAHOMA CITY OK
73117-1214
US

IV. Provider business mailing address

6700 W MEMORIAL RD APT 113
OKLAHOMA CITY OK
73142-6403
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-4544
  • Fax:
Mailing address:
  • Phone: 405-441-9800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberVF2
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: