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NPI Code Detail

MEDICARE: DR. EVAN DALE CLOTHIER D.D.S.

MEDICARE: DR. EVAN DALE CLOTHIER D.D.S.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11223G0001XGeneral Practice Dentistry7162KS
21223G0001XGeneral Practice Dentistry5817OK

General Provider Information

NPI Number : 1043261753
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. EVAN DALE CLOTHIER D.D.S.
Provider Business Mailing Address
First Line : 16534 E 49TH PL
Second Line :
City : TULSA
State : OK
Zip : 74134-7190
Country : US
Telephone Number : 918-251-8999
Fax Number :
Provider Business Practice Location Address
First Line : 300 N ASPEN AVE
Second Line :
City : BROKEN ARROW
State : OK
Zip : 74012-2205
Country : US
Telephone Number : 918-251-3333
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/15/2006
Last Update Date : 07/08/2007

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