Healthcare Provider Details

I. General information

NPI: 1053875690
Provider Name (Legal Business Name): HERO DENTAL OF OKLAHOMA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2019
Last Update Date: 01/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7715 E 91ST ST STE A
TULSA OK
74133-6060
US

IV. Provider business mailing address

2221 E BIJOU ST STE 100
COLORADO SPRINGS CO
80909-8009
US

V. Phone/Fax

Practice location:
  • Phone: 918-872-7009
  • Fax:
Mailing address:
  • Phone: 719-576-1850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: CHARLOTTE SOUDER
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 719-649-0305