Healthcare Provider Details

I. General information

NPI: 1588658470
Provider Name (Legal Business Name): LARS OLAV BOUMA DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4517 MEMORIAL CIR
OKLAHOMA CITY OK
73142-5004
US

IV. Provider business mailing address

4604 NW 161ST ST
EDMOND OK
73013-3250
US

V. Phone/Fax

Practice location:
  • Phone: 405-755-7777
  • Fax: 405-755-7169
Mailing address:
  • Phone: 405-285-5937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberPROSTHODONTICS 30
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number18073
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: