Healthcare Provider Details

I. General information

NPI: 1457210494
Provider Name (Legal Business Name): TALA AL AWWAD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2026
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1829 S WOOD DR
OKMULGEE OK
74447-6825
US

IV. Provider business mailing address

213 W CIVIC CENTER DR APT 328
SANDY UT
84070-1235
US

V. Phone/Fax

Practice location:
  • Phone: 918-756-6500
  • Fax:
Mailing address:
  • Phone: 805-453-7664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number8235
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: