Healthcare Provider Details

I. General information

NPI: 1790951614
Provider Name (Legal Business Name): ENDODONTIC SPECIALISTS OF NORTHEAST OK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

5555 E 71ST ST STE 9210
TULSA OK
74136-6542
US

IV. Provider business mailing address

5555 E 71ST ST STE 9210
TULSA OK
74136-6542
US

V. Phone/Fax

Practice location:
  • Phone: 918-524-3366
  • Fax: 918-524-3399
Mailing address:
  • Phone: 918-524-3366
  • Fax: 918-524-3399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number5644
License Number StateOK

VIII. Authorized Official

Name: ARMELLA GLENN
Title or Position: OFFICE MANAGER
Credential: BS
Phone: 918-524-3366