Healthcare Provider Details

I. General information

NPI: 1932821428
Provider Name (Legal Business Name): GREATER TULSA ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2022
Last Update Date: 09/13/2022
Certification Date: 09/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3916 E 91ST ST
TULSA OK
74137-3602
US

IV. Provider business mailing address

3916 E 91ST ST
TULSA OK
74137-3602
US

V. Phone/Fax

Practice location:
  • Phone: 918-488-8889
  • Fax: 918-488-0676
Mailing address:
  • Phone: 918-488-8889
  • Fax: 918-488-0676

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: DR. KENNER MISNER
Title or Position: OWNER
Credential:
Phone: 918-488-8889