Healthcare Provider Details

I. General information

NPI: 1700459559
Provider Name (Legal Business Name): OKC PROSTH PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2021
Last Update Date: 10/07/2021
Certification Date: 10/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11317 S WESTERN AVE STE 500
OKLAHOMA CITY OK
73170-5851
US

IV. Provider business mailing address

400 RIVERWALK TER STE 250
JENKS OK
74037-5619
US

V. Phone/Fax

Practice location:
  • Phone: 918-998-0996
  • Fax:
Mailing address:
  • Phone: 918-998-0996
  • Fax: 918-310-1056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: SARA BROWN
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 918-998-0996