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General NPI Number Information
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NPI Number | 1114292984
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Entity Type | Organization
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Legal Business Name | BEAU SPARKMAN D.D.S., P.A.
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Dates
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Enumeration Date | 03/13/2012
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Last Update Date | 03/13/2012
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Provider Practice Location Address
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Address Line | 104 W RAY FINE BLVD SUITE 5
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City | ROLAND
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State | OK
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Zip | 74954-5289
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Country | US
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Telephone | 918-503-6262
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Fax |
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Provider Business Mailing Address
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Address Line | 104 W RAY FINE BLVD SUITE 5
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City | ROLAND
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State | OK
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Zip | 74954-5289
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Country | US
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Telephone | 918-503-6262
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | BEAU SPARKMAN
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Credential | D.D.S.
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Telephone | 479-739-4999
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 6347
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License Number State | OK
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