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General NPI Number Information
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NPI Number | 1366775140
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Entity Type | Organization
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Legal Business Name | OB DENTAL, LLC
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Dates
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Enumeration Date | 09/11/2009
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Last Update Date | 09/11/2009
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Provider Practice Location Address
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Address Line | 1421 E 13TH ST
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City | TULSA
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State | OK
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Zip | 74120-5207
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Country | US
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Telephone | 918-585-3744
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Fax | 918-585-3774
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Provider Business Mailing Address
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Address Line | 1421 E 13TH ST
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City | TULSA
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State | OK
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Zip | 74120-5207
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Country | US
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Telephone | 918-585-3744
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Fax | 918-585-3774
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | DR. CHARLES R KEITHLINE
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Credential | DDS
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Telephone | 918-585-3744
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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 | 5859
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License Number State | OK
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