=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609669274
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSEPH ACQUAVIVA III DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2025
-----------------------------------------------------
Last Update Date | 05/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7130 W HEFNER RD
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73162-4502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-595-0585
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1216 SW 156TH TER
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73170-4314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-365-6575
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 8012
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------