=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467627364
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTRAL OKLAHOMA ORAL & MAXILLOFACIAL SURGERY ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2008
-----------------------------------------------------
Last Update Date | 04/23/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 812 S PINE ST
-----------------------------------------------------
City | STILLWATER
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74074-4349
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-624-1300
-----------------------------------------------------
Fax | 405-624-3084
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 812 S PINE ST
-----------------------------------------------------
City | STILLWATER
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74074-4349
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-624-1300
-----------------------------------------------------
Fax | 405-624-3084
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. SHAWNDA KAY PHARES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 405-624-1300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------