Healthcare Provider Details

I. General information

NPI: 1962677344
Provider Name (Legal Business Name): DR. MICAH J. BEVINS D.D.S.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2008
Last Update Date: 04/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6349 S MEMORIAL DR SUITE B
TULSA OK
74133-1928
US

IV. Provider business mailing address

6349 S MEMORIAL DR SUITE B
TULSA OK
74133-1928
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 Number
License Number State

VIII. Authorized Official

Name: MICAH JON BEVINS
Title or Position: GENERAL DENTIST
Credential: D.D.S.
Phone: 918-252-4444