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General NPI Number Information
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NPI Number | 1790942431
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Entity Type | Organization
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Legal Business Name | EAST NORMAN DENTAL
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Dates
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Enumeration Date | 05/20/2008
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Last Update Date | 05/20/2008
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Provider Practice Location Address
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Address Line | 443 12TH AVE NE
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City | NORMAN
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State | OK
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Zip | 73071-5241
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Country | US
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Telephone | 405-360-0018
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Fax | 405-360-1178
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Provider Business Mailing Address
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Address Line | 443 12TH AVE NE
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City | NORMAN
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State | OK
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Zip | 73071-5241
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Country | US
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Telephone | 405-360-0018
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Fax | 405-360-1178
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Authorized Official
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Title or Position | DENTIST
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Name | LARRY LAVELETT
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Credential | D.D.S.
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Telephone | 405-360-0018
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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 | 4835
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License Number State | OK
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