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General NPI Number Information
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NPI Number | 1306839246
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Entity Type | Organization
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Legal Business Name | SOUTHEAST OKLAHOMA ORAL & MAXILLOFACIAL SURGERY, PC
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Dates
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Enumeration Date | 08/25/2005
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Last Update Date | 05/06/2014
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Provider Practice Location Address
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Address Line | 803 N MONTE VISTA ST
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City | ADA
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State | OK
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Zip | 74820-7711
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Country | US
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Telephone | 580-332-3010
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Fax | 580-332-3010
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Provider Business Mailing Address
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Address Line | 803 N MONTE VISTA ST
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City | ADA
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State | OK
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Zip | 74820-7711
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Country | US
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Telephone | 580-332-3010
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Fax | 580-332-3010
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Authorized Official
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Title or Position | ORAL SURGEON AND OWNER
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Name | R. TODD BOONE
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Credential | DDS
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Telephone | 580-332-3010
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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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