Healthcare Provider Details

I. General information

NPI: 1700871779
Provider Name (Legal Business Name): MICAH J BEVINS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6349 S MEMORIAL DR SUITE B
TULSA OK
74133-1940
US

IV. Provider business mailing address

6349 S MEMORIAL DR SUITE B
TULSA OK
74133-1940
US

V. Phone/Fax

Practice location:
  • Phone: 918-252-4444
  • Fax: 918-252-4333
Mailing address:
  • Phone: 918-252-4444
  • Fax: 918-252-4333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number5650
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: