MEDICARE: WILLIAM M NYQUIST 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
1	1223G0001X	General Practice Dentistry	4127O	OK

General Provider Information

NPI Number	:	1548262314
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILLIAM M NYQUIST D.D.S.

Provider Business Mailing Address
First Line	:	11720 E 21ST ST
Second Line	:	SUITE A
City	:	TULSA
State	:	OK
Zip	:	74129-1824
Country	:	US
Telephone Number	:	918-437-9111
Fax Number	:	918-437-1684

Provider Business Practice Location Address
First Line	:	11720 E 21ST ST
Second Line	:	SUITE A
City	:	TULSA
State	:	OK
Zip	:	74129-1824
Country	:	US
Telephone Number	:	918-437-9111
Fax Number	:	918-437-1684

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

Provider Enumeration Date	:	08/11/2005
Last Update Date	:	09/27/2007

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