=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427154749
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LARRY O PRINCE DDS AND ASSOC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2047 W EDISON ST
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-584-9300
-----------------------------------------------------
Fax | 918-584-6308
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2047 W EDISON ST
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-584-9300
-----------------------------------------------------
Fax | 918-584-6308
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. LARRY O PRINCE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 918-584-9300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------