Healthcare Provider Details

I. General information

NPI: 1114287091
Provider Name (Legal Business Name): ON THE CUSP PEDIATRIC DENTISTRY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2012
Last Update Date: 08/14/2023
Certification Date: 08/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8222 E 103RD ST STE 133
TULSA OK
74133-7027
US

IV. Provider business mailing address

8222 E 103RD ST 133
TULSA OK
74133-7081
US

V. Phone/Fax

Practice location:
  • Phone: 918-970-4944
  • Fax: 918-970-4593
Mailing address:
  • Phone: 918-970-4944
  • Fax: 918-970-4593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. RYAN ROBERTS
Title or Position: OWNER/MEMBER
Credential: D.D.S., M.S.
Phone: 918-970-4944