Healthcare Provider Details

I. General information

NPI: 1245259779
Provider Name (Legal Business Name): JOHN BUBERT D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 10/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6565 S YALE AVE 910
TULSA OK
74136-8327
US

IV. Provider business mailing address

6565 S YALE AVE 910
TULSA OK
74136-8327
US

V. Phone/Fax

Practice location:
  • Phone: 918-743-3503
  • Fax:
Mailing address:
  • Phone: 918-743-3503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4001
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: