Healthcare Provider Details

I. General information

NPI: 1386328862
Provider Name (Legal Business Name): SANDRA MARIA PEROZO VAZQUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2023
Last Update Date: 06/14/2023
Certification Date: 06/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9607 E 95TH CT S
TULSA OK
74133-5839
US

IV. Provider business mailing address

6689 E 129TH ST S
BIXBY OK
74008-2503
US

V. Phone/Fax

Practice location:
  • Phone: 918-288-0818
  • Fax:
Mailing address:
  • Phone: 832-991-2555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number088
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: