Healthcare Provider Details

I. General information

NPI: 1225252919
Provider Name (Legal Business Name): ERIC JANKOWSKI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 10/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 FOREST RIDGE DR
TAHLEQUAH OK
74464-4191
US

IV. Provider business mailing address

504 FOREST RIDGE DR
TAHLEQUAH OK
74464-4191
US

V. Phone/Fax

Practice location:
  • Phone: 918-431-0138
  • Fax:
Mailing address:
  • Phone: 918-431-0138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDE00007834
License Number StateWA

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: