Healthcare Provider Details

I. General information

NPI: 1417179854
Provider Name (Legal Business Name): PROSTHETIC DENTISTRY OF TULSA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 03/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6565 S YALE AVE STE 505
TULSA OK
74136-8306
US

IV. Provider business mailing address

6565 S YALE AVE STE 505
TULSA OK
74136-8306
US

V. Phone/Fax

Practice location:
  • Phone: 918-502-6675
  • Fax: 918-502-6677
Mailing address:
  • Phone: 918-502-6675
  • Fax: 918-502-6677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number378925
License Number StateOK

VIII. Authorized Official

Name: DR. PAUL WAYNE WILKES
Title or Position: OWNER PRESIDENT
Credential: DDS MS
Phone: 918-502-6675