Healthcare Provider Details

I. General information

NPI: 1841465861
Provider Name (Legal Business Name): PREMIERE DENTISTRY OF TAHLEQUAH, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2008
Last Update Date: 05/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205 E ROSS BYP
TAHLEQUAH OK
74464-4188
US

IV. Provider business mailing address

1205 E ROSS BYP
TAHLEQUAH OK
74464-4188
US

V. Phone/Fax

Practice location:
  • Phone: 918-456-2555
  • Fax: 918-456-2444
Mailing address:
  • Phone: 918-456-2555
  • Fax: 918-456-2444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier200021320A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

Name: DR. ROBERT S JONES
Title or Position: DENTIST OWNER
Credential: DDS
Phone: 918-456-2555