Healthcare Provider Details

I. General information

NPI: 1396497319
Provider Name (Legal Business Name): KIMIKO AND TEDESCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2022
Last Update Date: 09/09/2025
Certification Date: 09/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11911 S OXFORD AVE STE 200
TULSA OK
74137-7778
US

IV. Provider business mailing address

11911 S OXFORD AVE STE 200
TULSA OK
74137-7778
US

V. Phone/Fax

Practice location:
  • Phone: 918-600-0026
  • Fax: 918-600-0690
Mailing address:
  • Phone: 918-600-0026
  • Fax: 918-600-0690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. BREANN H TEDESCO
Title or Position: OFFICE MANAGER
Credential:
Phone: 918-600-0026