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General NPI Number Information
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NPI Number | 1053635615
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Entity Type | Organization
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Legal Business Name | ROBERT L MIRACLE, DMD, PC
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Dates
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Enumeration Date | 03/25/2010
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Last Update Date | 03/25/2010
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Provider Practice Location Address
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Address Line | 1810 NW FERRIS AVE
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City | LAWTON
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State | OK
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Zip | 73507-5625
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Country | US
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Telephone | 580-355-1314
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Fax | 580-355-1027
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Provider Business Mailing Address
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Address Line | 1810 NW FERRIS AVE
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City | LAWTON
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State | OK
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Zip | 73507-5625
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Country | US
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Telephone | 580-355-1314
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Fax | 580-355-1027
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. ROBERT MIRACLE
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Credential | DMD
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Telephone | 580-355-1314
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 4 5347
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License Number State | OK
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