Healthcare Provider Details

I. General information

NPI: 1659960649
Provider Name (Legal Business Name): SMILE DOCTORS OF OKLAHOMA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2021
Last Update Date: 01/13/2021
Certification Date: 01/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4550 S HARVARD AVE
TULSA OK
74135-2906
US

IV. Provider business mailing address

PO BOX 674459
DALLAS TX
75267-4459
US

V. Phone/Fax

Practice location:
  • Phone: 918-749-8817
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: GREGORY GOGGANS
Title or Position: PRESIDENT
Credential:
Phone: 918-749-8817