Healthcare Provider Details

I. General information

NPI: 1508073438
Provider Name (Legal Business Name): GREGORY D SEGRAVES D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 07/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6132 E 61ST ST
TULSA OK
74136-2117
US

IV. Provider business mailing address

6132 E 61ST ST
TULSA OK
74136-2117
US

V. Phone/Fax

Practice location:
  • Phone: 918-494-8634
  • Fax: 918-494-8636
Mailing address:
  • Phone: 918-494-8636
  • Fax: 918-494-8636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number5930
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number30173
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: