Healthcare Provider Details

I. General information

NPI: 1275750184
Provider Name (Legal Business Name): ROMAN MICHAEL LOBODIAK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3232 E 31ST ST
TULSA OK
74105-2442
US

IV. Provider business mailing address

3232 E 31ST ST
TULSA OK
74105-2442
US

V. Phone/Fax

Practice location:
  • Phone: 918-743-1558
  • Fax: 918-742-2543
Mailing address:
  • Phone: 918-743-1558
  • Fax: 918-742-2543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number4367
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: