MEDICARE: ELIZABETH BOHANON DDS

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
1	1223G0001X	General Practice Dentistry	5826	OK

General Provider Information

NPI Number	:	1538234091
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH BOHANON DDS

Provider Business Mailing Address
First Line	:	555 W BENJAMIN HOLT DR
Second Line	:	BUILDING B
City	:	STOCKTON
State	:	CA
Zip	:	95207-3839
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7001 N MAY AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73116-3248
Country	:	US
Telephone Number	:	405-843-6000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/21/2006
Last Update Date	:	07/08/2007

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