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General NPI Number Information
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NPI Number | 1053986935
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Entity Type | Organization
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Legal Business Name | LIVE OAK ORAL SURGERY OF OKLAHOMA PLLC
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Dates
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Enumeration Date | 05/24/2021
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Last Update Date | 05/24/2021
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Provider Practice Location Address
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Address Line | 5405 SW DAUN
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City | LAWTON
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State | OK
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Zip | 73505-8508
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Country | US
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Telephone | 580-699-3131
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Fax | 580-699-3151
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Provider Business Mailing Address
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Address Line | PO BOX 258841
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City | OKLAHOMA CITY
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State | OK
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Zip | 73125-8841
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Country | US
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Telephone | 580-699-3131
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MICHAEL J GLIDDON
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Credential | DDS
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Telephone | 580-699-3131
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number |
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License Number State |
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