Healthcare Provider Details

I. General information

NPI: 1932879699
Provider Name (Legal Business Name): OKLAHOMA AESTHETIC RECONSTRUCTIVE SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2021
Last Update Date: 10/29/2021
Certification Date: 10/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13820 WIRELESS WAY
OKLAHOMA CITY OK
73134-2501
US

IV. Provider business mailing address

2708 W COUNTRY CLUB DR
OKLAHOMA CITY OK
73116-4219
US

V. Phone/Fax

Practice location:
  • Phone: 405-246-0391
  • Fax: 405-246-0392
Mailing address:
  • Phone: 405-246-0391
  • Fax: 405-246-0392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: STACEY DILL
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 405-735-9700