Healthcare Provider Details

I. General information

NPI: 1871255653
Provider Name (Legal Business Name): THOMAS BOURLAND
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2021
Last Update Date: 10/09/2021
Certification Date: 10/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 S ELWOOD AVE
TULSA OK
74119-4248
US

IV. Provider business mailing address

714 N BIRMINGHAM PL
TULSA OK
74110-5318
US

V. Phone/Fax

Practice location:
  • Phone: 614-706-1351
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: