Healthcare Provider Details

I. General information

NPI: 1548501133
Provider Name (Legal Business Name): TULSA DENTAL IMPLANTS AND PERIODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2013
Last Update Date: 12/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9607 E 95TH CT S
TULSA OK
74133-5839
US

IV. Provider business mailing address

8006 S 101ST EAST AVE STE B
TULSA OK
74133-4573
US

V. Phone/Fax

Practice location:
  • Phone: 918-288-0818
  • Fax:
Mailing address:
  • Phone: 918-288-0818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number6119
License Number StateOK

VIII. Authorized Official

Name: DR. TRUNG THANH TRAN
Title or Position: MEMBER
Credential: DDS
Phone: 918-288-0818