=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083499123
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENTAL ARTS OF LOCUST GROVE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2023
-----------------------------------------------------
Last Update Date | 08/28/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 409 E MAIN ST
-----------------------------------------------------
City | LOCUST GROVE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74352-5116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-888-5055
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 549
-----------------------------------------------------
City | LOCUST GROVE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74352-0549
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-888-5055
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SOREN MICHAELSEN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 405-593-9596
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------