=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154876258
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TULSA MODERN DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2016
-----------------------------------------------------
Last Update Date | 08/18/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3345 S HARVARD AVE SUITE 302
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74135-1812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-591-3535
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3345 S HARVARD AVE SUITE 302
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74135-1812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR OF DENTAL SURGERY
-----------------------------------------------------
Name | MARIAM G HANNA
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 918-591-3535
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------