Healthcare Provider Details

I. General information

NPI: 1295254068
Provider Name (Legal Business Name): SIH OKLAHOMA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 N WALKER AVE 547
OKLAHOMA CITY OK
73103-6405
US

IV. Provider business mailing address

4400 SHAWNEE MISSION PKWY STE 208
FAIRWAY KS
66205-2518
US

V. Phone/Fax

Practice location:
  • Phone: 800-492-4664
  • Fax: 913-747-1001
Mailing address:
  • Phone: 800-492-4664
  • Fax: 913-747-1001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GREGORY TULL
Title or Position: OWNER/PRINCIPAL
Credential: DMD
Phone: 913-254-4065