Healthcare Provider Details

I. General information

NPI: 1487875258
Provider Name (Legal Business Name): UNIVERSITY ORAL & MAXILLO FACIAL SURGEONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 08/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 N STONEWALL AVE RM 418A
OKLAHOMA CITY OK
73117-1214
US

IV. Provider business mailing address

PO BOX 26901 DCS209
OKLAHOMA CITY OK
73190-0001
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-5744
  • Fax: 405-271-4181
Mailing address:
  • Phone: 405-271-5744
  • Fax: 405-271-4181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number5360
License Number StateOK

VIII. Authorized Official

Name: PAUL MULLASSERIL
Title or Position: DIRECTOR OF MAXILLOFACIAL PROS
Credential: D.D.S. M.S.
Phone: 405-271-5744