Healthcare Provider Details

I. General information

NPI: 1316979040
Provider Name (Legal Business Name): PAUL EDWARD RADER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 N WATER AVE
TAHLEQUAH OK
74464-2825
US

IV. Provider business mailing address

217 N WATER AVE
TAHLEQUAH OK
74464-2825
US

V. Phone/Fax

Practice location:
  • Phone: 918-456-3521
  • Fax:
Mailing address:
  • Phone: 918-456-3521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4318
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier4318
Identifier TypeOTHER
Identifier StateOK
Identifier IssuerDENTAL LICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: