Healthcare Provider Details

I. General information

NPI: 1912217605
Provider Name (Legal Business Name): ORAL AND MAXILLOFACIAL SURGERY AT TULSA SURGICAL ARTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2010
Last Update Date: 10/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7322 E 91ST ST
TULSA OK
74133-6016
US

IV. Provider business mailing address

7322 E 91ST ST
TULSA OK
74133-6016
US

V. Phone/Fax

Practice location:
  • Phone: 918-392-7900
  • Fax: 918-392-0990
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number152
License Number StateOK

VIII. Authorized Official

Name: HUSAIN ALI KHAN
Title or Position: OWNER
Credential: M.D.
Phone: 404-805-2821