Healthcare Provider Details

I. General information

NPI: 1881704989
Provider Name (Legal Business Name): K GEORGE ELASSAL DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11317 S WESTERN AVENUE SUITE 100 A
OKLAHOMA CITY OK
73170-5849
US

IV. Provider business mailing address

11317 S WESTERN AVENUE SUITE 100 A
OKLAHOMA CITY OK
73170-5849
US

V. Phone/Fax

Practice location:
  • Phone: 405-692-2722
  • Fax:
Mailing address:
  • Phone: 405-692-2722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number4541
License Number StateOK

VIII. Authorized Official

Name: DR. K GEORGE ELASSAL
Title or Position: PRESIDENT
Credential: DDS
Phone: 405-692-2722